UNIVERSITY  OF  CALIFORNIA 
AT    LOS  ANGELES 


OS 
M 


LETTER    OF    TRANSMITTAL. 


U.  S.  Akmy  General  Hospital,   Washington   Barracks, 

Washinf/ton,  I).  C,  December  f),  1899. 

Brigadier  General  George  M.  Sternberg, 

Siirqeon-Gmeral,  Umted  States  Army. 
o  Sir-  I  have  the  honor  to  transmit  herewith  a  report  prepared  by  your 

,^  direction  on  the  use  of  the  Rontgen  ray  by  the  Medical  Department  of  the 

^  United  States  Army  in  the  war  with  Spain. 

"^  In  submitting  this  report,  I  desire  to  express  my  great  appreciation  ot 

the  earnest  support  you  have  given  its  preparation,  both  personall)'  and 
X  by  attording  me  every  possible  facility  for  the  work. 

'^  Very  respectfully,  your  obedient  servant, 

ji  .  W.  C.  Borden, 

x^  Captain  and  Assistant  Surgeon,  United  States  Anm/. 


352528 


TABLE    OF    CONTENTS. 


Page. 

Introduction 

Section  I: 

Eontgen  ray  apparatus  _ .  _ - -  - 

Static  apparatus 

Coil  apparatus 

Storage  batteries -*■* 

Primary  batteries ^^ 

Where  Rontgen  ray  apparatus  should  ])e  placed  for  military  surgical  use- .  18 

Eontgen  ray  apparatus  compared -  -  26 

Section  II: 

Lodged  missiles  — ''" 

Lodged,  Mauser  bullets  deformed  by  ricochet .  _  _ 33 

Lodged,  undef ormed,  Mauser  bullets -  35 

Lodged,  shrapnel  bullets  - . 37 

Lodged,  brass-jacketed  bullets 39 

Injuries  to  the  central  nervous  system  l)y  lodg°d,  Mauser  bullets 40 

General  conclu.sions  relative  to  lodged  missiles 44 

Section  III: 

The  localization  of  lodged  missiles -  -  '^^ 

The  Eontgen  ray  and  wound  (exploration  compared 45 

Necessity  for  the  localization  and  removal  of  lodged  missiles. -  46 

Localization  methods "*"' 

By  direct  observation ■*•' 

By  multiple  observation - 51 

Photo;;-raphic  apparatus  for  localization -     52 

Apparatus  for  visual  localization - -  - -  ^** 

Section  IV: 

Gunshot  fractures  of  the  diaphyses  of  long  bones  _  _ - 63 

Fractures  by  perforating  bullets *''^ 

Fractures  by  perforating  bullets  at  short  range 64 

Fractures  by  perforating  bullets  striking  the  bone  in  the  median 

line -  ^'>^ 

Fractures  by  liullets  striking  the  bone  tangentially 6it 

Fractures  by  penetrating,  undefoinied  bullets , 71 

Fractures  l)y  penetrating,  deformed  bullets 7^ 

Clinical  conclusions .  _    -  - '  "^ 

5 


6  CONTENTS. 

Section  V:  Papc. 
Giinsliot  fractures  of  tbo  oxtroniities  of  lony  hones  and  of  tlic  cancellous 

hones  <j;eneially - - - .  76 

Gunshot  of  the  epiphyses . .  76 

Gunshot  of  the  cancellous  bones - 81 

Clinical  conclusions -- —  83 

Skctiox  VI: 

Kadiographic  tecbnic 85 

The  static  machine - 85 

Crookes  tubes 86 

Manipulations  of  the  tube  to  secure  niaxinuim  i-adiation ,  - 87 

The  coil  machine -   . .  88 

Radioirnipliy - . . . .  90 

I'hotographic  plates itl 

Exposure . . . - .   - .  03 

Kuntireii  ray  1>urns .__ 93 

Development . 97 

Printing '... 98 


LIST    OF    ILLUSTRATIONS. 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIIL 

XXIX. 

XXX 

XXXI, 


PLATES. 

To  face  page 

The  Edison  battery  apparatus  and  the  .static  apparatus 14 

Lodficd.  Mauser  bullets 30 

Radiooraph  of  deformed,  Mauser  bullet  lodged  in  the  leg 3^ 

Radiograph  of  deformed,  Mauser  bullet  lodged  superficially  in  knee  U 

Radiooraph  of  undeformed,  Mauser  bullet  lodged  in  the  thigh 3(5 

Lodged,  shrapnel  bullets, ^o 

Radiograph  of  shrapnel  bullet,  lodged  in  the  back 38 

Radiograph  of  shrapnel  l)ullet,  lodged  in  thigh 38 

Lodged,  bra.ss-jacketed  bullets ^^ 

Radiograph  of  Mau.ser  l)ullet,  lodged  in  the  back -i^* 

Radiograph  of  Mauser  bullet,  lodged  in  the  brain   4^ 

Radiograph  of  fragment  of  missile,  lodged  in  the  fibula 48 

Radiograph  of  Mauser  bullet,  lodged  in  the  foot 52 

Radiograph  of  Mauser  bullet  fracture  of  metacarpal  bones 66 

Radiogi'aph  of  Mauser  bullet  fracture  of  radius  by  •■contact"  --.  66 

Radiograph  of  Mau.ser  bullet  fracture  of  femur 68 

Radiograph  of  Mauser  bullet  fracture  of  femur  after  union 68 

Radiograph  of  Mauser  bullet  fracture  of  phalan.x QS 

Radiograph  of  Mauser  bullet  fracture  of  metatarsal  bones 68 

Radiograph  of  Mauser  bullet  fracture  of  humerus 7(i 

Radiograph  of  Mauser  bullet  fracture  of  radius -  7(i 

Radiograph  of  Mauser  bullet  fracture  of  humerus 7(> 

Radiograph  of  Mauser  bullet  fracture  of  femur 7(» 

Radiograph  of  Mauser  bullet  fracture  of  humerus 72 

Radiograph  of  Mauser  bullet  fracture  of  ulna 72 

Radiograph  of  Mauser  bullet  fracture  of  femur  by  "nmshroomed" 

bullet -  -    -  ■^^ 

Photograph  of    bone  fragments  from  a  ca.se  of    fracture  of   the 

thigh  by  a  '' mushroomed"  Mauser  bullet 72 

Radiograph  of  gunshot  fracture  of  the  fenmr              74 

Radiograph  of  fracture  of  tibia  by  brass-jacketed  bullet 74 

Radiograph  of  Mauser  bullet,  embedded  butt-end  foremost  in  the 

tibia 'i'" 

Radiograph  of  shrapnel  bullet  in  the  thigh,  the  bullet  having  per- 
forated the  fenuir  .    - ■  '6 

7 


8  ILLUSTRATIONS. 

To  face  page 

XXXII.   Hadiofrrupli  of  Mauser  bullet  fraeture  of  neck  of  femur 78 

XXXIII.  Hadiojrraph  of  Keniin<rton  bullet,  lodged  in  upper  end  of  tibia 78 

XXXIV.  Kadiojrraph  of  Krair-.Torgeiisen  perforation  of  upper  end  of  tibia.  80 
XXXV.  Kadiofrniph  of  separation  of  olecranon  by  Mauser  bullet 80 

XXXVI.  Ridioirraph  of  fracture  of  lower  end  of  radius  by  lodged,  Mau.ser 

l>ullet - --  -  -  80 

XXX\'I1.  Radiograph  of  Remington  bullet  perforation  of  o.s  calcis 82 

XXXVIII.   Ridiograph  of  Remington  bullet.  lodged  in  the  face  ..  - 82 

FIGURES. 

1.  Edison-Lalande  cell 16 

2.  Edison.  l)reak-wheel  apparatus 28 

8.  Diagram  of  location  of  ball  in  case  of  Private  Keene,  First  United  States 

Volunteer  Cavalry 35 

4.  Diagram  of  location  of  bullet  in  case  of  Private  Cooper,  Tenth  Cavalry  .-  3lj 

5.  Diagram  explanatory  of  Plate  ^^I 38 

6.  Diagram  explanatory  of  Plate  VIII     _ 38 

7.  Diagram  sht>\ving  location  of  bullet  in  ca.se  of  Edward  Marshall - .  41 

8.  Photograph  of  Private  Gretzer.  First  Nebraska  Volunteers -  43 

9.  Diagram  showing  location  of  bullet  in  case  of  Major  Eskridge 47 

10.  Diagram  showing  relative  size  of  umbi'a  and  penumbra  in  foreign  todies 

lodged  in  the  tissues 50 

1 1.  Mackcnzie-David.son  exposer _ 53 

12.  Mackcuzic-Dayidson  localizer 54 

13.  Diagram  showing  method  of  using  localizer 68 

14.  Diagram  showing  method  of  localization 58 

15.  Harri.son  portable  localizing  apparatus    60 

16.  Dennis  fluorometer 60 

17.  Diagram  illustrating  lateral  transmission  of  energy  by  osseous  tissue 65 

18.  Diagram  explanatory  of  Plato  XIV 66 

19.  Diagram  explanatory  of  Plate  XVI 67 

20.  Diagram  explanatory  of  Plate  XX 69 

21.  Diagram  explanatory  of  Plate  XXVI 73 

22.  Diagram  explanatory  of  Plate  XXIX           74 

23.  Diagram  explanatory  of  Plate  XXXII         78 

24.  Diagram  explanatory  of  Plate  XXXVI          81 

25.  ROntgen  ray  burn,  case  of  Private  ^IcKenna 94 

26.  Rontgen  ray  burn,  case  of  Private  Booth 95 


THE   USE 

III'  THK 

RONTGEN     RAY 

BY   THE 

MEDICAL  DEPARTMENT  OF  THE  UNITED  STATES  ARMY 

IN  THE 

WAR   WITH   SPAIN. 

(  1S9S.  ) 


THE  USE  OF  THE  RiiNTGEN  RAY  BY  THE  MEDICAL  DEPARTMENT  OF  THE 
UNITED  STATES  ARMY  IN  THE  WAR  WITH  SPAIN. 


INTRODUCTION. 

Soon  after  the  discovery  by  Professor  Rontgen  of  the  new  form  of 
radiation  and  the  placing  on  the  market  of  apparatus  for  its  production,  the 
Surgeon-General  of  the  Army  supplied  Rontgen-ray  apparatus  to  several 
of  the  larger  post  hospitals.  On  the  outbreak  of  the  war  with  Spain  and 
the  establishment  of  general  hospitals  the  most  prominent  and  important  of 
these  hospitals  and  the  three  hospital  ships  Reliefs  Missouri,  and  Bay  State 
were  su[)plied  with  similar  appliances. 

In  all,  seventeen  apparatus  were  available  during  the  war,  of  which  five 
were  static  and  twelve  were  coil  machines.  These  apparatus  proved  to  be 
not  only  invaluable  aids  hi  military  surgery,  but  the  use  of  the  two  types, 
coil  and  static,  gave  an  opportunity  for  comparison  of  these  two  methods 
for  producing  the  Rontgen  ray  as  adapted  t(^  the  needs  and  environments 
of  military  ho.spitals. 

The  use  of  the  Rontgen  ray  has  marked  a  distinct  advance  in  military 
surgery. 

It  has  favored  conservatism  and  promoted  the  aseptic  healing  of  bullet 
wounds  made  by  lodged  missiles,  in  that  it  has  done  away  with  the  neces- 
sity for  the  exploration  of  wovmds  by  probes  or  other  means,  and  by 
this  has  obviated  the  dangers  of  infection  and  additional  traumatism  in.  this 
class  of  injuries. 

In  gunshot  fractures  it  has  been  of  great  scientific  value  by  showing 
the  character  of  the  bone  lesions,  the  form  of  fracture,  and  the  amount  of 
bone  comminution  produced  by  the  small-caliber  and  other  bullets — condi- 
tions which  could  not  have  been  otherwise  determined  in  the  living  body. 

In  the  treatment  of  these  traumatisms  it  has  been  of  great  value  in 

determining  the  course  of  treatment  to  be  pursued,   as  its  use,   together 

with  the  course  of  the  cases  under  treatment,  has  shown  that  aseptic  or 

11 


12  k(")nt(;en  ray  in  spanish-american  war. 

septic  roudition  of  tlu-  wouuil  is  of  far  gTeater  importance  than  the  amount 
(if  V)one  coinininutiou.  Tliis  is  ilhistrated  by  those  cases  of  extensive  bone 
connninntion  which,  when  connected  with  aseptic  wounds,  progress  to 
favorable  termination  with  a  miuinunn  of  immediate  and  remote  ill  effects; 
while  those  cases  in  which  the  bone  traumatism  is  slight,  if  complicated  by 
infection  of  the  wound,  are  much  more  difficult  to  ti-eat  and  serious  in  their 
result. 

In  the  sections  of  this  report  which  are  devoted  to  a  consideration  of 
the  effects  produced  by  missiles,  care  has  been  taken  to  select  the  cases  and 
radiogi-aphs  which  are,  as  far  as  possible,  typical  of  the  conditions  treated  of. 

In  making  these  selections,  many  case  reports  and  radiographs, 
which  have  been  submitted  to  the  Surgeon-General,  and  which  are  similar 
to  those  introduced  in  the  text,  have  been  omitted,  as  the  reproduction  of 
radiographs  which  onlv  show  that  which  is  illustrated  by  those  introduced 
would  add  to  the  bulk  of  the  report  without  increasing  its  value.  As  the 
scientific  value  of  tlie  ])lates  depends  upon  their  being  true  representations 
of  the  objects  as  shown  by  the  Riintgen  ray,  the  radiographs  and  the  nega- 
tives, from  which  they  were  printed,  have  not  in  any  case  been  retouched 
other  than  to  remove  some  slight  defects  which  may  have  appeared  in  the 
prints  or  negatives  during  their  prepai'ation.  In  this  connection  the  writer 
wishes  to  express  his  appreciation  of  the  work  done  bv  Dr.  W.  31.  Grav,  of 
the  Amiy  Medical  Museum,  in  preparing  many  of  the  negatives,  and  of  the 
preparation  of  many  of  the  prints  by  Private  Hany  Utter,  Hospital  Corjjs, 
United  States  Army. 

In  the  sections  devoted  to  teclmic,  the  theory  and  physics  of  Rontgen 
radiation  have  been  omitted  as  ha^^ng  no  practical  bearing  upon  the  use  of 
the  Rontgen  ray  in  militaiy  surgery,  and  these  sections  have  been  devoted 
to  questions  of  practical  teclmic,  knowledge  of  w  liicli  has  proved  of  value 
in  manipulating  the  apparatus  used  to  produce  the  new  kind  of  radiation. 


I. 

RONTGEN   RAY  APPARATUS. 

Two  types  of  a])paratus — coil  and  static — were  in  use  in  the  Medical 
Department  of  the  United  States  Army  during  the  Spanish-American  war. 
In  both  apparatus,  Rontgen  rays  are  produced  by  passing  a  rapidly  inter- 
rupted electrical  current  of  high  potential  tlu-ough  a  specially  constructed 
glass  Ijullj  (Crookes  tube)  of  liigh  vacuum.  In  the  static  machine,  the 
electrical  current  is  produced  directly  by  the  machine  and  can-ied  direc^t 
from  it  to  the  tube.  The  electrical  enei'gy  given  out  by  the  static  machine 
is  derived  from  the  motor  energy  used  in  di-iving  the  machine. 

In  the  coil  machine,  the  electrical  current  is  produced  in  the  secondary 
portions  or  coils  of  a  special  appai-atus — Ruhmkorif  coil— by  induction 
through  the  passage  of  a  primary  current  of  low  potential  through  the 
primary  portions  or  coils  of  the  apparatus. 

The  primary  current  is  obtained  from  many  forms  of  elecjtrical  sources; 
either  from  primary  batteries,  accumulators,  dynamo  machines,  or  from 
local  electrical  installations,  and  is  led  to  the  Ruhmkorff  coil  by  means  of 
insulated  wires. 

In  the  Ruhmkorff  coil,  the  primary  current  traverses  the  primary  coil, 
which  is  placed  within  the  secondary  coil,  and  in  so  doing  induces  a  second- 
ary current  of  high  potential  in  the  outer  or  secondary  coil.  This  secondary 
cun-ent,  after  being  interrupted  with  high  frequency  by  mechanical  means, 
is.  carried  to  the  tube  and  there  gives  rise  to  the  peculiar  form  of  energy 
known  as  Rontgen  radiation. 

When  working  properly,  both  the  static  and  the  coil  apparatus  produce 
Rontgen  rays  <»f  practically  equal  power  ;ind  working  efficiency.  The 
ai)paratus  are,  however,  so  utterl}'  unlike  in  construction  and  require  such 
different  means  for  their  manipulation  that  they  are  not,  under  all  condi- 
tions, equally  adapted  to  the  requirements  of  military  surgery. 

13 


14  U()NT(iK.\  KAY  IN  SPANISH- AMEKK A \  WAR. 


THE  STATIC  APPARATUS. 

Tlic  Static  niacliiues  iu»w  used  for  the  production  of  Kiintgeii  radiation 
areof  theWiiushurst-Holtz  type,  which  iiichides  a  charger  and  an  inthiction 
apparatus,  the  latter  consisting  of  eight  or  ten  circular  glass  plates  su])- 
ported  on  an  axle,  with  intervening  oblong  plates  of  glass,  combs,  connections, 
etc.,  all  inclosed  in  a  case  of  glass  and  wood.  The  circular  plates  are 
revolved  ])y  hand  or  by  motor  power.  With  the  latter,  a  motor  of  one-sixth 
to  one-fourth  horsepower  is  required.  The  static  machines  used  by  the 
Medical  Depai-tmeut  were  made  by  Otis  Clapp  &  Son,  of  Pro^^dence,  R.  I. 
Their  apjiaratus  weighs  about  500  pounds,  is  well  constructed  and  reliable, 
and,  with  proper  manipulation,  gives  Rontgen  rays  of  high  power. 

COIL    APPARATUS. 

The  coil  machines  used  by  the  Medical  Department  were  of  several 
different  patterns.  They  comprised  those  made  l)y  the  Kdison  Manufactur- 
ing Company,  the  Fessenden  Company,  and  the  General  Electric  Company. 

In  these  apparatus,  the  primary  current  is  supplied  from  primary  bat- 
teries, st<n-age  batteries,  or  dynamos,  and  all  these  different  means  were 
in  use  during  the  war.  The  Edison  machines  were  the  type  operated  bv 
Edi.son-Lalande  cells.  Tlie  Fessenden  machines,  and  that  of  the  General 
Electric  Company,  were  supplied  with  storage  batteries  or  with  current  from 
dynamos.  Where  a  dynanu)  current  can  be  had  it  is  tlie  best  kind  of  cur- 
rent, as  it  is  always  ready  toi-  use  and  can  be  had  in  sufficient  and  con.stant 
quantity.  It  is,  however,  rai-ely  a\ailali]e  for  Rontgen  rav  apparatus  used 
for  military  purposes,  except  on  liospital  ships,  as  few  military  hospitals  are 
supplied  with  electric  plants  or  are  situated  where  cun-ent  from  them  can 
be  obtained.  In  consequence,  primary  or  secondary  (storage)  batteries. 
ortUnarily  have  to  be  used. 

STORAGE    HATTERIES. 

These  batteries  when  in  good  working  order  yield  excellent  results, 
'i'heyare  objectionable  on  account  of  their  bulk  and"  weight,  and  especially 
from  their  being  apt  to  get  out  of  order  aufl  yi.dd  currents  uncertain  in 
quantity  unless  they  are  constantly  used  and  carefully  attended  to.  An<  .ther 
disadvantage  is,  that  as  they  are  an  intermediary  method  of  supphiug 
electricity,  they  require  a  source  from  which  to  obtain  their  charge.     Where 


PLATE   I. 


PLATE  1 


The  Edison  Battery  Apparatus. 


The  Static  Apparatus. 


Plate  I. 


RONTGEN  RAY  APPARATUS.  '15 

wai-  ships  oi-  electric-lio-ht  plants  are  available  the  problem  of  their  supply 
is  easily  solved.  But  this  is  rarely  the  case.  'Hie  British  iiiedical  depart- 
ment in  the  Soudan  expedition'  overcame  the  ditiiculty  of  charging  storage 
batteries  by  charging  them  from  a  dynamo  I'un  l)y  means  of  a  tandem 
i)icvcle  attachment.  This  method  is  objectionable  in  that  it  requires  an 
extra  amount  of  complex  apparatus  and  time  and  labor  to  run  the  machine, 
while  the  i-esulting  out])Ut  of  electricity  is  no  better  or  greater  than  that 
obtained  direct  from  [jrimary  batteries. 

In  the  Spanish-iVmerican  war  a  storage  batter}'  was  at  first  used  on  the 
hospital  ship  Relief,  but  its  weight  and  bulk,  and  the  difficulty  experienced 
in  keeping  it  in  order,  caused  its  use  to  be  abandoned. 

PRIMARY    UATTKRIES. 

But  one  type  of  primary  battery  has  been  used  by  the  Medical  Depart- 
ment of  the  United  States  Army. 

These  batteries  are  made  up  of  Edison-Lalande  cells  in  direct  series. 

The  medical  department  of  the  British  army  made  use  in  the  Terah 
campaign  of  a  battery  of  Grove  cells,  and  with  it  obtained  excellent  results.^ 
The  Edison-Lalande  cell  is  nnuOi  more  constant  and  steady  in  action  than 
the  Grove  cell,  and  is  undoubtedly  the  best  form  of  i)rimary  battery  for 
Rontgen  ray  purposes.  The  cell  used  is  the  tyi)e  W  of  the  Edison  Manu- 
facturing Company.  It  consists  of  a  porcelain  jar  7.^  by  15  inches,  with 
the  contained  elements  and  solution.  Ten  of  these  cells  are  united  in  direct 
series  to  form  the  battery  for  Rontgen  ray  work,  and  all  are  inclosed  in  a 
metal-lined  zinc  box. 

The  elements  employed  in  the  Edison-Lalande  cell  are  zinc,  which 
forms  the  negative  pole,  and  black  oxide  of  copper  (CuO),  the  positive 
pole  of  the  battery.  The  exciting  liquid  is  a  solution  of  caustic  potash. 
The  oxide  of  copper  is  obtained  by  the  ])rocess  of  roasting  copper  turnings; 
the  oxide  is  then  ground  into  a  tine  powder  and  compressed  into  sohd 
blocks,  from  which  plates  of  a  suitable  size  for  the  different  cells  are  cut. 
These  plates  are  suspended  from  the  cover  of  the  containing  vessel  (a 
porcelain  jar),  in  a  grooved  copper  frame,  the  sides  of  which  are  rigidly 
bolted  to  the  cover  by  means  of  tinnnb  nuts,  one  of  which  also  serves  as 
the  positive  pole  of  the  battery.     On  each  side  of  the  copper  oxide  element 

'Battersby,  J.  "The  present  position  of  tlie  Rocntf.'cii  rays  in  military  snrgery,"  Archives  of  the 
Roentgen  Ray,  Vol.  Ill,  page  74.     London,  ISHd. 

^Beevor.     "The  worliing  of  the  Riintgen  ray  in  warfarr,"  .lovn-nal  i>(  the  Royal  I'niteil  Service 
Institntion,  Vol.  XLII,  page  1152.      London,  1898. 
B648 2 


16 


R()NTUEN  HAY   IN  SPANISH-AMERICAN  WAR. 


iu  tilt.'  i-t'Us  is  su.s|icii(le(l  a  nillcd  zinc  plate.  These  zinc-  ])lat('s  are  fastened 
by  a  bolt  to  a  knob  on  the  cover.  This  prevents  any  movement  in  the 
relative  position  of  the  elements,  and  does  away  with  tlie  necessity  of  using 
vulcanite  se])arators  to  jtrevent  anv  .short  circuits  occurring  in  the  solution. 
The  zincs  are  amalgamated  and,  as  in  most  l)atteries,  the  zinc  is  attacked 
more  vigorously  near  the  top  than  at  the  lower  part  of  the  \)h\ie,  the  zincs 
for  this  cell  are  made  slightlv  tapering,  the  thick  part  being  uppermost. 

The  exciting  liquid  employed  in  the  battery  consists  of  a  25  per  cent 
.solution  of  caustic  potash  in  water,  or  in  other  words,  of  a  solution  of  1 
pound  of  caustic  potash  in  o  ])ounds  of  water.  AVhen  the  circuit  is  closed 
and  the  cell  is  put  iu  action,  tlu'  wati-r  is  decomposed,  the  oxygen  forming, 


Fhi.  1.— Edisoii-U-laudu  i-i-ll.  ly|.c  \V. 


with  the  zinc,  oxide  of  zinc,  which,  in  turn,  condtines  with  the  potash  to 
form  an  exceedingly  .soluble  double  salt  of  zinc  and  jyotash,  which  di.s.solves 
as  rapidly  as  it  is  formed;  the  hydrogen,  liberated  by  tlie  decomposition  ot 
the  water,  reduces  the  copper  oxide  to  metallic  coi)i)er.  A  layer  of  heavy 
paraffin  oil  three-eighths  of  an  inch  deep  is  added  to  keep  out  the  air  and 
prevent  creeping. 

The  Edis(m-Lalande  battery  has  an  initial  electromotor  force  of  0.95 
volt,  which  drojjs  to  0.7  volt  on  closed  circuit.  At  first  sight  it  appears 
that  the  electro-motive  force  is  low.  The  internal  resistance  is,  however, 
corresjiondiugly  lower  (in   the  ty[)e    \V   cell   being  only  0.02  ohm),  and 


PRIMARY  BATTP:RIES. 


17 


c-diisequently  it  follows   that   the  available  electrf)-niotive  force  (potential 
diliereiice)  is  very  high. 

The   efficiency  of  the   Edison-Lalande  cell   as   compared   with   other 
primary  batteries  is  shown  in  Table  I. 


Table  I.  Dr.  A.  E.  Kenndlya  tahL-  shaaung  comparative  efficiency  tenU  het-wwn  the 
Edison-Lalande  cell,  type  W,  and  other  t.ype^s  of  hatteiy  mi  the  marhet,  fo7' 
purposes  of  driving  small  electric  i/iotors,  or  for  moderate  general  delivery  of 
power. 


Type  of  eell. 


1.   Mean 
working,  E. 
M.  F.  volts. 


Edison-Lalande,  type  W  . 

Fuller  bichromate 

Western  Union  carbon, 

bichromate  type 

Partz  motor  eel  1 

Hussey  Eclipse 

Leclanohe 

Gravity  Daniell,  Western 

Union  type,  local 


0.67 
1.8 

1.8 
1.83 

1.4 
1.6  toO.  .5 


1.0 


2.  Aver- 
age inter- 
nal resist- 
ance. 

3.  Maxi- 
mum de- 
livery 
current. 

4.  Capac- 
ity in 
am  pere 
hours. 

5.  Power 
valuation. 

6.  Eco- 
nomic 
power 
valuation. 

Ohms. 

A  tnperes. 

0.028 

33.35 

300 

22.  22 

4.58 

0.40 

4.50 

68 

8.1 

8.1 

0.40 

4.50 

5 

8.1 

6.48 

0.51 

3.58 

65 

6.57 

1.458 

0.8 

1.75 

45 

2.  45 

0,98 

0.5 
0.5 

3.0 
2.0 

1.0 
2.0 

1.0 
2.22 

The  third  column  gives  the  current  that  the  cells  will  deliver  when 
placed  on  short  circuit,  and  the  fourth  and  fifth  columns  show  the  great 
capacity  in  ampere  hours  and  the  high-power  valuation  of  the  type  W 
cell  compared  with  other  similar  sources  of  electrical  energy. 

The  Edison-Lalande  battery  has  the  following  advantages  for  Rontgen 
ray  work : 

1.  High  and  constant  available  electromotive  force. 

2.  Little  loss  of  energy  while  the  cell  is  idle,  the  chemical  action  in 
the  cell  being  only  about  1  per  cent  a  month. 

3.  Constant  and  heavy  current  delivery. 

4.  No  attention  or  inspection  required  until  the  elements  are 
exhausted. 

5.  Freedom  from  noxious  fumes  or  chemical  deposits.  No  freezing  or 
influence  by  temperature  changes  or  differences. 

6.  Comparatively  cheap  materials,  easily  obtained. 


18  KONTGEN  KAY  IN  SPAM81J-AMER1CAN  WAR. 

The  Routgen  rav  battery  of  ten  cells,  type  W,  luis  a  life  of  GOO  ampere 
limu-s,  or  about  "200  wi^rking  liours.  The  cost  of  renewal  of  the  elements 
is  about   S22,  making-  the   hourly   running  cost   only  about  11  cents  per 

hour. 

The  Edison  battery  apparatus  complete,  as  furnished  the  ^ledical 
Dejjartment,  is  as  follows: 

1  Edisoii-Kuhiiikorif  coil.  6-inch  .spark,  with  adjustable  condenser  and  vibrator. 

1  P^dison  tluoroscope,  6  inches  by  S  inches. 

1  Edison  X-ray  focus  tube,  medium  size. 

1  Edison  X-ray  focus  tube,  large  size. 

1  adjustable  stand  for  tube. 

10  Edison -Lalande  cells,  type  W,  in  metal-lined  polished  oak  box. 

1  combination  rheostat,  for  using  battery  for  X-ray.  cautery,  motor,  diagnostic,  and 

centrifugal  work. 
1  battery  cord,  connecting  combination  rheostat  to  coil. 
1  battery  cord,  connecting  battery  to  combination  rheostat. 
•2  insulated  wires  for  connecting  tube  to  coil. 

For  a  battery  apjjaratus,  this  outfit  is  quite  compact  and  can  be  trans- 
ported without  danger  of  breakage. 

WHERE   RONTGEN   RAY  APPARATUS   SHOULD   BE   PLACED    FOR    MILITARY   SURGICAL 

USE. 

Before  comparing  the  different  tvpes  of  apparatus  it  should  be  deter- 
mined where  the  apparatus  is  to  be  placed  for  use. 

In  the  Spanish-American  war,  apparatus  were  supplied  to  general 
hospitals  and  hospital  shij)s  only.  Xoiie  were  used  in  movable  hospitals  or 
in  the  field.  Some  advocates  of  the  Rontgen  ray  in  military  surgery  have 
advised  the  use  of  apparatus  in  the  field  hospitals.  In  the  Tei'ah  expedi- 
tion an  api)aratus  was  used  at  the  extreme  front — so  far  to  the  front  that 
the  operate u's  were,  at  one  time,  under  fire  when  engaged  in  removing  a 
bullet  with  its  aid. 

Experience  with  its  use  in  the  late  war  and  the  conditions  of  military 
surgery  lead  to  the  conclusion,  that  the  use  of  the  apparatus  in  niovaljle 
hospitals  is  not  advisable,  and  that  its  use  should  be  restricted  to  perma- 
nent l)ase  and  general  ho.spitals  and  to  ho.spital  ships.  This  conclusion  is 
reached  through  a  combhiation  of  reasons: 

First.  Tliat  lodged  bullets  only  in  exti-emel)'  rare  cases  require  imme- 
iiate  removal. 


Rr)NT(iJEN  RAY  APPARATUS.  19 

Second.  That  the  environments  of,  and  conditions  incident  to  moval)le 
tield  hospitals,  render  asepsis  in  operating'  practicably  impossible;  and,  in 
consequence,  in  field  hospitals  noninterference  with  wounds  should  be 
practiced  to  the  utmost  extent  possible. 

Third.  That  surgical  interference  with  lodged  bullets,  except  where 
adequate  asepsis  is  available  or  the  necessity  urgent,  is  to  be  condemned,  as 
the  suppuration  which  follows  is  much  more  detrimental  to  the  patient  than 
the  presence  of  the  lodged  missile. 

Foui'th.  That  a  Rontgen  ray  apparatus  in  the  field  is  an  additional 
incentive  to  surgeons  to  operate  under  conditions  not  adequately  aseptic. 

The  percentage  of  the  recoveries  of  the  wounded  in  the  war  with 
Spain  was  high  compared  with  preceding  wars,  as  will  be  seen  by  reference 
to  Table  II,  which  shows  the  comparative  mortality  of  the  wounded  in 
recent  wars. 

In  the  American  civil  war,  where  the  larger  caliber  rifle  was  used  and 
asepsis  and  antisepsis  were  unknown,  the  mortality  was  nearly  double  that 
of  the  Spanish-American  war  (12.96  to  6.64  per  cent). 

The  question  naturally  arises,  how  much  of  the  reduction  in  mortality 
is  due  to  the  use  of  a  smaller  caliber  rifle  firing  a  small  bullet  with  high 
velocity  and  how  much  is  due  to  modern  surgical  methods.  In  an  attempt 
to  determine  this  question,  attention  is  called  to  Table  III,  which  shows  the 
mortality  of  regional  wounds  in  the  two  wars.  From  this  table,  it  will  be 
seen  that  the  mortality  from  wounds  of  the  head,  face,  neck,  spine,  and 
abdomen  did  not  materially  diff"er  in  the  two  wars.  There  was,  however,  a 
marked  difi'erence  in  the  chest  wounds  (27.8  to  11.4),  and  a  very  great  dif- 
ference in  wounds  of  the  extremities  and  flesh  wounds  of  the  back.  The 
great  difi'erence  in  mortality  from  injuries  of  the  pelvis  and  genital  organs 
is  mainly  to  be  ascribed  to  the  fact  that  these  injuries  recorded  in  the 
Spanish-American  war  were  mostly  flesh  wounds,  while  in  the  civil  war 
many  penetrating  wounds  of  the  pelvis  and  severe  fractures  of  the  pelvic 
bones  were  tabulated. 


20 


liUNTCiEN  KAY  IN  SPANISH-AMERICAN  WAR. 


Taiu.k  ll.—]Vumher  of  womided  in  recent  wars  who  mnw  under  treatment  and  per- 
centage of  mortality. 


Wounded. 

Died. 

Mortality. 

Per  cent. 

12,094 

1,840 

15.21 

39,  868 

4,  359 

10.90 

17.0.54 

2,962 

17.36 

l'4ii.  712 

31,978 

12.96 

2,021 

316 

15.63 

13,  731 

1,455 

10.59 

99,  566 

11,023 

11.07 

56, 652 

6,824 

12.04 

1,105 

108 

9.77 

948 

99 

10.44 

1,594 

106 

6.  64 

( 'riinoaii.  lS54-;i6— English  (Matthew ') 

Krench  (Uhenu  *) 

In  Italy,  IS5i)-iiM— Krem-h  (Chenu ')  

.\nn'rUan  livil,  1861-<>.^— Federals  (Otis ') 

I'riissia-Denmark,  1864— Prussians  ( Loeffler  ^) 

.Viistria-Prus.<ia,  1866— Pru.^sians  (Uieffler ") 

France-tierniany,  1870-71— CJennans  (official ' ) 

Russia-Turkey,  1877-78— Russians  (Kosloff ") 

China-.Tapan,  1894-9.5— .Japanese  ;  Third  Division  (Haga  '1 . 
Indian  frontier,  1897-98- English;  Terahexpedition  ((iore"") 
.^panish-.Vnierieaii,  1S9S— Americans  (official  ") 


•  Matthew.  Medical  and  Surgicjil  History  of  the  British  Army  in  the  Crimea,  Vol.  II,  p.  259. 
London,  1858. 

'  Chenn.  Rapport  au  Conseil  de  Sant^  des  Armies  sur  les  resultats  du  Serxice  Jledico- 
Chirurgical  aux  .Vinl)ulances  des  Crimee,  18.54, 1855, 1856.     Paris,  1865. 

The  nuiuher  of  deaths  among  the  wounded  and  the  mortality  of  the  wounded  as  here  given  are 
much  lower  than  given  by  most  writers  for  the  French  forces  in  this  war,  the  mortality  of  the 
wounded  usually  being  stated  at  about  25  per  cent. 

As  most  writers  in  giving  the  high  mortality  of  about  25  per  cent  ijuote  Chenu  as  authority,  it  is 
probable  that  an  original  error  of  computation  was  made  by  some  writer  quoting  Chenu  and  that  this 
has  been  perpetuated.  Chenu  himself  states  that  while  his  figures  can  not  be  considered  as  absolutely 
accurate  that  there  is  probably  but  slight  error.  They  may,  therefore,  be  considered  sufficiently 
accurate  for  general  deductions. 

'Chenu.  Statistique  M(?dico-ChirurgicaIe  de  la  Campagne  d' Italic  en  1859  et  1860,  Tome  II, 
p.  853. 

'  Otis.  Medical  and  .-lurgical  History  of  the  War  of  the  Retiellion,  Vol.  Ill,  pp.  685-691. 
Washingtiin,  1883.     The  figures  cover  wounds  made  by  weajions  of  war. 

'  Loeffier  (F).  tienend-Bericht  iiber  den  Gesuudheitsdienst  im  Feldzuge  gegen  Diinemark, 
1864,  Erster  Thcil,  pages  36-46.     Berlin.  1867. 

'  LoefHer  (F).  Das  Preussische  Milit;ir-^Iedezinalwesen  und  seine  Reform  nach  1866,  II,  Table 
I.     Berlin,  1868. 

'  Sanitiits-Bericht  iiber  die  I)eut.schen  Heere  im  Kriege  gegen  F^rankreich,  1870-71.  Berlin, 
1888.     II.  Bund,  II,  p.  94. 

"  Kosloff.  Compte-Rendu  du  Service  de  Sant^*  Militaire  pendant  la  liuerre  de  Tunpiie  de 
1877-1878  d'aprC's  les  donnees  officielles.     St.-Petersbourg,  1887. 

These  ligures  differ  widely  from  those  of  Pirogow,  which  are  often  quoted  and  which  give  the 
mortality  of  the  wounded  at  2(>.03  [ht  cent.  Pirogow's  figures  are  entirely  erronedus,  being  ba.sed  on 
estimates  only  and  not  on  utticial  records. 

'  Haga.  Kriegschirurgische  Erfanrungen  aus  deni  .lapanisch-Chinesischen  Krieg,  1894-95. 
Archiv  fiir  klinische  Chirurgie,  vol.  .55,  pp.  256-2.57.     Berlin,  1897. 

'"Gore.  Army  Medical  Department  (British)  Report,  1897.  Appendix  Xo.  VI,  "p.  4.51. 
I><uidon,  1898. 

Tlie  ligures  are  the  wounde<l  of  the  Terah  expeditionary  force  only. 

"  li(.-port  of  the  .Vdjntanl-General  of  the  .\rmy  to  the  Secretary  of  War.  1899.  Tables  facing 
pp.  10  and  16.     Washington,  1899. 


GUNSHOT  STATISTICS. 


21 


Table  III. — Ifwmher,  reglomd  dixtrlbutimi^  and  iiMrtallty  of  gunxhot  mmndfi  in  cases 
which  came  under  treatment  in  the  Aiaerican  cii^il  imr  and  the  Spanish- jhnerican 
vmr.  ^ 


Civil  war. . 
S.-A.  war. . 

Civil  war . . 
S.-A.  war. . 


Seat  and  character  of 
injury. 


Total  number  (if 
cases. 


Head. 
Flesh  wounils. . 

Fracture.'^ 

Flesh  wounds. . . 
Fractures  

F,MC. 

Flesh  wounils 4,  914 

Fractures |     4,  502 


7,739 
4,350=12,089 

40 

31=         71 


43 
16  = 


Civil  war. 
S.-A.  war. 

Civil  war. 
S.-A.  war. 

Civil  war. 
S.-A.  war. 


35  = 


ti42  = 
8  = 


Flesh  wounds. . 

Fractures  

yak. 

Fle.-^h  wciuiids 4,895 

Flesh  wounds 

Injuries  nf  spine. . 

Injuries  of  spine  . . 
C/icsf. 

Nonpenetrating  . . 

Penetratin;/ 

Nonpenetrating 

Penetrating 

AhdoiiiL'n. 
Civil  war. . .  I  Nonpenetrating  . . 

Penetrating 

S.-A.  war. . .    Nonpenetrating  . . . 

Penetrating 

Pi'rincuiii  (iikI  yai- 
ilal. 

Injuries  of  pelvis. 

Flesh  wounds  of 
genito- urinary 
organs. 

Perineum  and  gen- 
ital. 

BcAck. 

Flesh  wounds  of 
back. 

Flesh    wounds    of 

back  and  hips. 
Upper  e.iirtmilii'x. 

Flesh  wounds 

P'ractures 

Flesh  wounds 

Fractures  

Lturi'r  ('.rfi-f'iiiiiit'.^. 

Fle.sh  wounils 

Fractures 

Flesh  wounds 

Fractures  


9,  41« 
59 

4,  895 
35 


642 
8 


11,995 

8,  269=20,  264 
61 
53=       114 


Civil  war. . 

S.-A.  war. . 

Civil  war. . 
S.-A.  war. . 

Civil  war. . 
S.-A.  war. . 

Civil  war. . 
S.-A.  war, . 


4,  748 
3,  690= 
20 
44  = 


1,494 
1,  665= 


S,  438 
64 

3,  159 


7=  7 

12,681  =  12,681 
108=        108 


.^)4,  801 
32,992=87,793 

289 

140  = 


Per  cent  of  fn- 
•  jueiii'V. 


3.14 

1.76=  4.9 
2.86 
2.21=  5.07 

1.99 

1.83=  3.82 
3.07 
1.14=  4.21 


Recover- 
ies. 


6,  573 

51 

7,  406 

54 


1.99  = 
2.50= 


1.99 
2.50 


0.26=  0.26 
0.57=  0.57 

4.87 

3.36=  8.23 
4.38 
3.79=  8.15 


1.93 
1.50= 
1.43 
3.14  = 


3.  43 

4.57 


0.60 
0.67=  1.27 


0.50=  0.50 

5.  15=  5. 15 
7.72=  7.72 


22.29 

13.39=35.68 
20.66 
429  1  10.00=30.66 


59, 139  24.  06 

27,274=86,413  \  11.09=35.15 

354  25. 30 

150=       504  ,  10.72=36.02 


Undeter- 
Deaths.  I  mined 
results. 


,496 
26 


279 
3 


13,  921 
99 

3,  455 
35 

2,194 
7 

10,  883 
106 

80,  090 
426 

73, 665 
490 


2,  676 
18 


462 
4 


2,  840 
2 


1..548 
1 


Per  cent 

of 
mortality. 


618 

7 

781  1 
2 

349 
5 

14 
0 

5,  373 

970 

13 

2 

3,  293 

1,690 

29 

0 

930 

35 

0 

0 

1 

800 

998 

2 

0 

5,608 

2,095 

1 

2 

11,813 

935 

8 

« 

28.9 
26.1 

5.  9 
6.89 

1.5.0 
21.2 

55.  57 
62.5 

27.  85 
11.6 

48.  80 
45.3 

29.77 
00.0 

6.85 
1.9 

6. 54 
0.20 

13.8 
1.6 


'The  cases  from  the  civil  war  are  compiled  from  the  Surgical  History  of  the  War  of  the  Rebellion. 
The  cases  from  the  Spauish-.Vnu'rican  war  are  those  which  occurred  in  the  Regular  troops,  and  which 
are  reported  in  the  Report  of  the  Surgeon-General  of  the  Army  fur  1899,  complete  records  of  the 
Volunteer  troops  not  yet  being  availal>le. 


'->'> 


KOMXiEN  HAY  IN  bl'ANlSH-AMlilUCAN  \VAH. 


The    o-reat   reduftion    in   inortaHt\-  in    wounds  of  the  extremities  is 
especially  noticeable  (Table  IV). 

Table  IV. — A^umber  of  cases  and  mortal  it  1/  from  gunshot  of  the  extremities  in  t/ie 
civil  war  and  United  States  JRignhirs  in  Spanish-Amet^ican  tear. 


Cases. 

Died. 

Mortality. 

Pivil  wiir  in>npr  extrpmiti^s           .    . 

87,  793 
429 

86,  413 
562 

5,608 

1 

11, 813 

9 

6.5 

0.2 

13.6 

1.6 

Spanish-American  war,  upper  extremities 

Civil  war   lower  t^\ti"6UiitiL'S                               -    ..    ............ 

Snanish-American  war.  lower  extremities .... 

Tliusin  the  civil  war,  while  the  mortality  of  all  wounds  of  the  extremi- 
ties, upper  and  lower,  was  6.5  and  13.6  per  cent,  similar  wounds,  in  the 
Spanish-American  war,  had  a  total  mortality  of  but  1.0  per  cent.  The  number 
of  deaths  in  the  latter  war  from  wounds  of  these  regions  were  surprisingly 
small,  being  but  10  in  991  cases,  and  of  these  10  cases,  3  died  very  shortly 
after  the  receipt  of  their  injunes,  probably  from  hemorrhage.'  The  differ- 
ence in  treatment  adopted  in  these  wars  is  not  less  great  than  the  mortalitv 
(Table  V). 

Table  V. —  ^Vounds  of  the  extremities  treated  hi/  excision  and  amprdation,  and  hy 
conservatism,  aiid  the  relative  mortality  of  each  treatment  for  two  wars  {in 
Spanish-American  war.  United  States  Beg%dars). 


War. 

Wounds  of  extrem- 
ities. 

Amputations  and 
excisions. 

Percentage 
of  opera- 
tions to 
wounds. 

Operative 
mortality. 

Conserva- 
tive mor- 
tality. 

Total. 

Deaths. 

Total. 

Deaths. 

Civil 

Spanish-American 

174,206 
991 

17,421      12,193 
10             32 

2,636 
6 

6.99 
3.20 

21.6 
18.7 

9.1 
0.4 

This  table  shows  at  once  (a)  the  small  number  of  operations  done  or 
required  to  be  done  in  wounds  of  the  extremities  since  the  adoption  of  the 
new  rifle  and  modern  surgical  methods,  the  proportion  having  been  reduced 
over  one-half  (6.99  to  3.20);  (li)  the  great  decrease  in  mortality  in  these 
cases,  the  morality  being  reduced  over  twenty-two  times  in  cases  treated 
conservatively  (9.1  to  0.4)  and  somewhat  decreased  in  those  treated  by 
amputation  or  excision. 

'  Report  of  the  Surgeon-General  of  the  Army,  1899,  p.  314.     Wa-shington,  1899. 


rOntgen  ray  apparatus. 


23 


The  hio'h  mortality  in  operation  cases  in  the  Spanish-American  war 
arose  from  the  fact  that  only  the  extremely  serious  cases  were  operated  on. 
In  the  cases  reported  among  the  Regulars,  the  deaths  that  occurred  were  all 
from  high  amputations  (Table  VI). 

Table  VI. — Rexn'tiom,  amputat-i/m,<i,  and  de(tth.'^  from  these  operations  im,  the  Spcmish- 

American  var  {Regidar  troops). 


Arm 

Forearm . . 
In  hand  . . 
Hip  joint . 
Thigh . . . . 

Knee 

Leg 

Ankle 


Resections. 


Total. 


Amputa- 
tions. 


4 
2 
13 
2 
.5 
1 
1 
1 


29 


Deaths.i 


'  No  deaths  from  resection. 

These  tables  demonstrate  that  the  lower  mortality  in  gunshot  of  the 
extremities  in  the  Spanish-American  war  was  accompanied  with  increased 
conservative  treatment.  That  the  conservative  treatment  which  was  prac- 
ticed was  made  possible  entirely  through  a  difference  in  effect  produced 
by  the  small  calil)er  bullet  from  that  produced  by  the  old  lead  bullet 
can  not  be  entertained.  The  Riintgen  ray  examinations  have  shown  that 
in  compound  fractures  the  amount  of  bone  comminution  is  generally  as 
great  with  the  new  as  with  the  older  bullet,  and  the  writer's  observations 
upon  shrapnel  bullet  wounds  have  led  him  to  believe  that  slow-moving 
lead  bullets  very  frequently  produce  wounds  practically  as  aseptic  as  those 
made  by  the  new  bullet.^  It  follows,  that  conservatism  has  been  made 
possible  mainly  tlii-ough  (a)  the  fact  of  the  recognition  of  the  general  aseptic 
nature  of  bullet  wounds;  {h)  the  maintenfTuce  of  their  asepticity  by  the  use 
of  occlusive  dressings;  and  (c)  the  treatment  of  septic  wounds  by  antiseptic 
methods. 

The  Routgen  i-ay  has  played  an  important  part  in  allowing  the  surgeon 
to  preserve  the  asepticity  of  bullet  wounds  by  doing  away  in  many  cases 

'Borden.     Gunshot  woimds:  A  report  of  gunshot  cases  in  the  Spanish-American  war.     New  .York 
Medical  Journal,  Vol.  LXXI,  New  York,  1900. 


24  kOxt(;en  ray  in  spanish-american  war. 

with  the  necessity  for  iminechate  wound  ex})l«)iariou,  especially  for  lodged 
bullets. 

The  many  cases  of  lodged  bullets  in  which  the  liullets  were  left  undis- 
tiu-bed  until  the  patients  reached  a  general  hospital  or  hospital  ship,  where 
tlie  missiles  were  located  liy  the  Riintgen  ray  and  removed  under  aseptic 
technic  with  complete  safety  to  the  patient  and  rapid  recovery,  prove  the 
nonnecessitv  for  the  use  of  Rontgen  ray  apparatus  in  field  or  other  advanced 
hospitals.  Even  where  the  bullet  can  be  readily  located  without  the  use  of 
the  RoTitgen  ray,  the  experience  of  the  late  war  and  tlie  opinion  of  numerous 
authorities  lead  to  the  conclusion  that  tlie  zeal  of  the  surgeon  should  not 
cause  him  to  remove  the  missile  at  the  field  hospital  except  in  special  cases. 
Infection  is  almost  sure  to  occur  from  the  almost  absolute  impossibility  of 
obtaining  asepsis  under  conditions  which  are  present  at  the  front,  and  the 
recovery  of  tlie  patient  is  delayed  and  the  functions  of  the  wounded  part 
likely  to  be  impaired  in  consequence  of  the  suppuration  which  will  follow. 
Von  Bergmann,  who  obtained  such  briUiaut  results  in  the  Turko-Russiau 
war  by  the  use  of  occlusive  dressing,  and  who  has  since  advocated  the  use 
of  such  dressings  and  noninterference  in  gunshot  wounds,^  has  expressed 
the  opinion  that  the  Rontgen  ray  will  prove  a  menace  in  military  surgery 
in  that  its  use  will  prove  an  incentive  to  unnecessary  operative  interference. 

In  a  recent  clinical  lecture  he  said : 

After  many  years'  pi'actice  in  peace  and  in  war  I  maintain  that  foreign  bodies, 
the  presence  of  which  in  the  t)ocly  is  not  a  source  of  any  trouble  or  danger,  ought  to 
be  left  where  they  are. 

The  consciousne.ss  of  having  some  extra  lead,  for  instance,  in  one's  body, 
e.sipecially  when  it  causes  one  no  inconvenience  whatever,  does  not  in  the  least 
counterbalance  the  danger  of  an  operation  necessary  for  its  removal. 

This  is  especiallj^  the  case  in  war,  when  it  is  often  impossible  to  operate  with 
all  aseptic  precautions.  If  special  merit  was  ascribed  to  me  in  the  Russo-Turkish 
war  I  ascribe  it  partly  to  the  fact  that  when  my  colleagues  came  up  with  bullet 
probes  of  every  kind  I  dissuaded  them  from  their  purpose.  Even  then  I  had  a 
tough  t)attle  to  tight — a  battle  which  is  not  quite  ended  even  yet.  and  will  now,  after 
ROntgen's  discovery,  begin  afresh. 

Professc^r  Kuttner,'  of  Lubingen,  who  followed  the  Greek  war  in 
connection  with  the  German  Red  Cross  Society,  has  stated,  as  a  result  of 
his  experience  with  a  Rontgen-ray  apparatus  m  that  war,  that  the  Rontgen 

'  V.  Bergmann.     Die  Re.sultate  der  Geleukresectionen  im  Kriege.     Giessen,  1874. 
v.  Bergmann.    Die  Behandhing  der  8chus^<\vunden  des  Kniege-lenks  im  Kriege.    Stuttgart,  1877. 
'  Kuttner  (H.).     Ueber  die  Bedeutung  der  Rontgen  strahlen  fiir  die  Kriegschirurgie  nach 
Erfah'rungen  im  (Jricchiwh-Tiirkischen  Krieg,  1897. 

Beitrage  zur  Klinischen  Chirurgie  XX,  p.  167.     Tiibingen,  1898. 


rOntgen  ray  apparatus.  25 

rays  are  of  great  importance  for  medical  aid  in  war,  bnt  only  for  fixed 
hospitals  and  those  installeil  in  fortresses,  while  lV>r  moving-  field  hospitals 
their  apjjlication  is  very  limited. 

Abbott,'  in  an  article  in  the  London  Lancet  of  Jannary  14,  1899,  on 
Surgery  in  the  Gra-co-Turkish  war,  states  that  a  coil,  battery  apparatus  was 
used  in  the  base  hospital  at  Phalerum.  As  a  result  of  his  experience  in 
this  war,  he  says  : 

The  use  of  the  Rontgen  ray  becomes  an  iinpossibility  at  the  actual  front.  For- 
tunately it  is  not  necessary  there,  and  could  very  possibly  do  harm  by  stinnilating 
the  young  surgeon  to  premature  operations  under  l)ad  surroundings.  We  believe 
that  the  X-ray  in  future  wars  will  be  of  the  greatest  use.  hut  not  at  the  actual  front. 

In  closing  his  article  Abbott  formulates  the  following: 

The  apparatus  is  of  no  use  on  the  field  where  the  detection  of  bullets  ean  only 
be  an  incentives  to  premature  exploration. 

The  less  wounds  are  tampered  with  before  satisfactory  suri'oundings  are  reached 
the  l)etter. 

The  modern  bullet  *  *  *  is  practieally  useptie.  and  there  is  no  urgency  for 
its  removal. 

Surgeon  Major-General  Jameson,  of  the  medical  department  of  the 
British  arm}-,  in  discussing  the  use  of  the  Rontgen  ray  in  warfare  and  as 
used  by  the  British  medical  department,  says: 

Reference  has  l)een  made  to  the  necessity  of  supplying  these  various  apparatuses 
to  the  hospitals  at  the  front,  but  the  difficulty  of  transport  nuist  really  be  considered. 
It  seems  to  me  that  from  our  present  knowledge  the  advantages  are  not  so  very  great 
after  all  in  that  part.  The  place,  I  think,  for  them  is  in  the  line  of  communication 
or  at  the  base  hospital,  l)ecause  after  all  nothing  except  very  urgent  operations  are 
advised  to  be  performed  in  advanced  places.  What  the  photography  really  deter- 
mines is  more  the  position  of  the  l)ullet  or  the  kind  of  fracture,  but  the  urgency  of 
operation  is  determined  by  other  conditions. ' 

Our  experience  in  the  war  with  Spain  was  full}-  in  accord  with  the 
above  opinions,  as  the  use  of  the  Rontgen-ray  apparatus  at  general 
hospitals  and  on  board  hospital  ships  met  all  practical  requirements. 

As  to  the  use  of  the  Rontgen  ray  in  gunshot  fractures,  the  same  rules 
hold  as  for  lodged  missiles;  i.  e.,  occlusive  dressings  and  noninterference  at 
the  field  hosiiitals  except  where  operation  is  imperatively  demanded,  and  in 
this  connection  it  may  be  stated  that  cases  of  gunshot  fractures  are  extremely 

1  Abbott,    (F.  C).     Surgery  in  the  Graeco-Turkish  War.     Lancet,   Vol.  I,   pp.   :W  and   152. 

London,  1899. 

■'Journal  of  the  Royal  United  Service  In.stitution,  Vol.  XLII.  London,  18HS.  Janie.siin  i\\t^- 
cussing  Beevor'H  paper  "The  woikiiij;  of  the  Riintjien  ray  in  warfare." 


26  RONTGEN  KAY  IN  SPANISH-AMERICAN  WAR. 

infnniiK'iu  which  can  be  benefited  in  any  way  by  tlie  use  of  Rontgen 
apparatus  at  the  trout. 

Also,  in  considering  where  Rontgen  apparatus  are  to  be  placed  for  use  iu 
military  surgery  in  time  of  war,  the  fact  must  be  taken  into  account  that  these 
apparatus  are  all  more  or  less  bulky,  heavy,  somewhat  difficult  to  transport, 
and  that  their  use  requires  c<Misiderable  experience,  and  at  field  hospitals 
necessitates  expenditure  of  time  when  surge<ms  are  most  Ijusy  with  work 
incident  to  active  operations.  These  disadvantages  should  not  be  considered 
were  the  Ijenefits  to  be  derived  from  the  employment  of  these  apparatus  in 
field  liospitals  at  all  in  ])roportion  to  the  difficulties  incident  to  their  trans- 
portation and  use.  But,  when  the  benefits  to  be  derived  from  using  them  at 
advanced  liospitals  is  confined  to  extremely  few,  if  any  cases,  and  is  useless 
in  all  others,  the  time,  work,  and  transportation  expended  on  these  appa- 
ratus under  such  circumstances  can  be  better  employed  in  other  ways. 

In  view  of  these  facts,  it  appears  that  the  place  for  Riintgen-ray  appa- 
ratus is  at  base  and  general  hos|)itals  and  on  hospital  ships,  and  that 
apparatus  so  located  will  meet  all  requirements  compatible  with  the  condi- 
tions incident  to  the  practice  of  military  surgery.  With  apparatus  so 
located.  Ront"en-rav  examinations  can  be  followed  when  necessary  by 
proj)er  asej)tic  or  antiseptic  operative  methods.  This  plan  of  locating  and 
using  Rontgen-ray  apparatus  was  adopted  in  the  Spanish-American  wai' 
with  the  best  possible  results. 

,       RONTGEN-KAV    APPARATUS    COMPARED. 

Premising  that  these  ap})aratus  are  to  be  used  at  base  and  general 
hospitals,  it  will  not  be  necessary  to  sacrifice  efficiency  to  too  great  com- 
pactness or  convenience  for  transportation. 

At  the  same  time,  the  apparatus  should  not  only  be  efficient  and  not 
too  complex  or  difficult  to  ope: ate,  but  it  should  not  be  eft'ected  by  climatic 
or  atmospheric  conditions,  and  should  be  fairly  portable. 

The  choice  of  machines  necessarily  lies  between  two  types — the  static 
and  the  coil.  WHien  properly  managed  the  two  machines  are  practically 
equally  effective.  Theii-  adaptability  for  use  in  military  surgery  rests, 
therefore,  entirely  with  which  best  meets  the  requirements  above  given. 
These  re([uirements  are  undoubtedly  usually  best  met  by  some  form  of 
coil  machine. 

The  static  machine  is  bulky  and  heavy,  glass  enters  largely  into  its 
construction,  and  consequently  it  can  not  t>rdinarily  be  as  easily  or  safely 


DIFFERENT  APPARATUS  COMPARED.  27 

transported  to,  or  set  up  at  hospitals  established  tor  military  purposes  as 
can  the  coil  apparatus.  It  is  subject  to  a  certain  extent  to  atmosplieric 
influences,  and  while  these  can  be  laro-ely  overcome  bv  pi'ojter  ])recautious, 
they  add  to  the  difficulty  ot  obtaining  g-ood  work.  The  apjjaratus  can  l)e 
run  by  hand  power;  but,  when  so  run,  its  output  is  not  eqi;al  to  that  of  the 
same  machine  when  run  by  motor  power  at  an  even  rate  <it  s])eed.  To 
run  the  static  machine  by  hand  for  any  length  of  time  is  exceedingly  tire- 
some, even  with  a  relay  of  men,  while  motors  add  to  the  expense  and 
trouble  of  transportation  and  installation  of  the  apparatus. 

The  advantages  of  the  static  apparatus  are  that,  when  ]jroj)erlv  managed, 
it  gives  a  constant  output  which  is  at  any  time  available  and  that  it  is 
economical  in  tubes,  as  tubes  do  not  wear  out  so  rapidh-  with  it  as  with  the 
coil  machine.  In  permanent  military  hospitals  in  dry  climates,  and  espe- 
cially where  motor  power  is  available  and  a  dynamo  current  is  not  to  be  had, 
the  static  apparatus  will  give  a  constantly  available  and  steady  source  of 
Rontgen  radiation. 

Relative  to  the  coil  machines,  taking  the  Edison  fi-inch  coil  machine 
run  with  10  Edison-Lalaude  cells  as  a  type,  this  form  of  apparatus  lias  the 
a,dvantages  over  the  static  machine  of  less  weight,  greater  portability,  less 
complexity,  and  nonliability  to  climatic  or  atmospheric  influences.  The  bat- 
tery is  easily  set  up,  easily  run,  lasts  for  a  long  time,  and  the  cost  of  main- 
taining it  in  use  is  not  great.  Coil  apparatus  can  be  transported  with 
comparative  ease  and  with  a  minimum  danger  of  breakage.  These  are  all 
decided  advantages  in  times  of  active  operations  where  apparatus  have  to  be 
shipped  to  recently  established  hospitals  and  used  more  or  less  constantly 
under  disadvantageous  conditions.  A  battery  apparatus  can  be  quickh'  set 
up,  and  by  having  a  supply  of  extra  charges  on  hand  for  the  battery,  the 
apparatus  can  always  be  kept  in  working  order.  For  these  reasons,  in  time 
of  war,  where  hospitals  are  being  established  and  equipped,  the  coil  apparatus 
with  primary  batteries  is  best  for  general  hospitals  and  base  hospitals  where 
dynamo  currents  can  not  be  obtained. 

The  battery  apparatus  has  the  disadvantage  of  requiring  a  certain 
amount  of  care  to  keep  the  battery  up  to  its  maximum  working  efficiency 
and  of  not  giving  currents  of  absolutely  equal  streugtli.  With  the  JMlison- 
Lalande  cells  these  disadvantages  are  reduced  to  a  miniimim,  and  in  time 
of  active  operations,  when  the  machines  are  being  used  frequentlv, 
give  rise  to  no  decided  trouble.  In  established  hosi)itals,  in  time  of 
peace,  where  an  apparatus  is  used  infrequently,  and  where  it  can  be  phiced 
in  a  good  room  and  well  attended  to,  a  static  machine  is  probabh-  to  be 


28 


KONTCJEN  RAY  TX  SPANISH-AMERICAN  WAR. 


preferred  to  oiU'  ojjerated   1)}'  a  l)attery,  particularK-  where  motor  jxiwer  is 
available. 

Where  dynamo  currents  can  he  had,  the  coil  machines  of  the  "  break- 
wheel  "  type  will  give  the  greatest  efficiency.  No  machine  of  this  type 
was  in  use  during  the  war  with  Spain,  as  none  of  the  general  hospitals  were 
supplied  with  dynamo  cun-ents.  Since  the  war,  an  ajiparatus  of  this  type 
has  been  placed  in  the  hospital  connected  witli  the  Soldiers'  Home  in 
this  city   (Washington,    I).  C).     The   writer   has   carefully   examined  this 


Edison  hreak-uhecl  apparatus. 


apparatus  and  believes  tliat   in   hospitals  where  a  dynamo  current  can  be 
had,  this  ap])aratus  should  lie  supplied  to  the  exclusion  of  any  other. 

The  distinctive  feature  of  the  "  break-wheel "  ai)paratus  is  that  there 
IS  no  vibratoi-  on  the  induction  coil,  its  place  being  taken  by  an 
instantaneous  air  break-wheel  device.  This  device  consists  of  two,  toothed 
wheels  mounted  on  the  same  shaft,  the  projections  or  teeth  making  contact 
with  two  flat  brashes  which  bear  on  the  outer  peripheries  and  by  which  the 
cun-ent  is  brought  in  and  led  out  again.     'Jliese  wheels  are  rotated  at  veiy 


DIFFERENT  APPARATUS  COMPARED.  29 

high  speed  by  a  small  direct- current  motor,  which  also  runs  a  pressure 
blower.  The  air  blast  from  this  blower  enters  a  bifurcated  tube  and  is 
connected  with  two  flat  nozzles  immediately  over  the  contact  brushes. 
When  the  device  is  set  in  operation  by  starting  the  motor  and  connecting 
the  primary  of  the  coil  in  series  with  the  binding  post,  the  spark,  formed  at 
the  contact  brushes  when  the  coil  is  energized,  is  instantaneously  blown  out 
by  the  air  blast  at  the  moment  of  formation.  Tliis  greatly  increases  the 
rapidity  of  change  in  the  magnetic  circuit,  and  consequently  vastly 
augments  the  electric-motor  force  in  the  secondar}^  coil.  In  consequence, 
Rontgen  radiation  of  higher  penetration  and  efficiency  is  produced  in  the 
tube.  The  apparatus  can  be  worked  only  by  110  to  120  volt  direct 
current. 

The  whole  ap]iaratus,  with  the  exception  of  the  coil,  is  in  an  oak 
cabinet.  It  is  extremely  compact,  strongly  made,  and  not  liable  to  get 
out  of  order  or  be  affected  by  atmospheric  conditions.  It  surpasses  all 
apparatus  with  which  the  writer  is  familiar,  both  as  to  ease  of  operation 
and  quantity  and  penetration  of  its  Rontgen-ray  output.  As  it  requires 
a  direct  current  of  110  to  120  volts  to  operate  it,  it  is,  of  course,  only 
applicable  in  military  surgery  in  those  hospitals  and  hosjiital  ships  which 
are  supplied  with  this  form  of  electrical  current. 

The  general  conclusions  reached  relative  to  the  kind  of  Rontgen-ray 
apparatus  best  adapted  to  militar}'  surgical  use,  and  the  place  in  which  the 
apparatus  should  ])e  used,  are: 

First.  The  place  for  the  apparatus  is  at  general  hospitals,  permanent 
hospitals  on  the  line  of  conmuinication,  and  on  hospital  ships. 

Second.  That  in  equipping  base  and  general  hospitals  for  war  service, 
coil  a])])aratus  actuated  b}'  ])rimary  batteries  should  be  sujiplied. 

Third.  That  in  permanently  established  hospitals,  where  there  is  no 
dynamo  current  available,  the  static  machine  will  probably  give  best 
satisfaction,  especially  if  motor  power  can  be  had. 

Fourth.  That  in  permanent  base  hospitals,  or  on  hospital  ships  sujiplied 
with  direct  cui-rents  of  110  to  120  volts,  the  "break-wheel"  apparatus 
will  give  the  highest  obtainable  efficiency. 


II. 

LODGED     MISSILES. 

The  penetrating'  and  perforating  power  of  a  missile  depends  upon  the 
reh^tion  which  its  velocity,  its  weight,  its  sectional  density  and  its  form 
bear  to  the  constitution  of  the  obstacle  against  which  it  impinges.  Witli 
the  modern  jacketed  bullet  these  proportions  are  such,  relative  to  animal 
tissues,  that  the  bullet  usually  perforates  the  part  against  which  it  impinges 
unless  its  velocity  is  greatly  reduced  Reduction  in  velocity  may  arise 
from  long  range  or  from  the  missile  having  imj)inged  against  some  other 
object  before  striking  the  body.  In  the  first  case,  loss  of  penetrating  and 
perforating  power  is  due  entirely  to  decreased  velocity  of  the  ball.  In 
the  second  case,  it  may  be  due  to  decreased  velocity  from  previous  impact 
or  its  power  maybe  further  lowered  by  deformation  in  shape,  so  decreasiuii 
its  penetrating  or  perforating  power  b}'  altering  its  form  and  decreasing 
its  sectional  density. 

Even  with  velocity  so  lowered  that  perforating  power  is  lost,  the 
jacketed  bullet,  when  undeformed,  almost  invariably  travels  in  a  right  line 
after  entering  the  body.  This  peculiarity  of  the  bullet  is  probably  due  in 
part  to  its  form,  but  mainly  to  its  great  sectional  density.  In  this  it  differs 
markedly  from  the  old  lead  bullet  of  large  caliber,  with  whfch  deflections, 
after  entering  the  body,  were  extremely  common. 

The  small-caliber  bullet  is  sometimes  found  lying  at  an  angle  to 
its  com-se  of  entrance.  This  slight  displacement  may  be  produced  by 
contact  of  the  bullet  with  some  of  the  more  resistant  tissues  of  the  body, 
l)ut  in  the  soft  tissues  it  is  probable  that  slight  displacement  of  the  bullet 
from  the  line  of  its  course  is  often  due  to  muscular  action  or  pressure  by 
neighboring  tissues  after  the  bullet  has  come  to  rest.  Thus  in  Case  14  of 
this  section,  where  the  bullet  was  embedded  in  the  brain  and  consequently 
was  not  acted  upon  by  such  forces,  the  bullet  lies  exactly  in  the  line  of  its 
course;  while  in  Case  6  of  this  section,  and  Case  6,  Section  V,  the  bullets 
have  been  displaced,  probably  by  pressure  from  neighboring  tissues,  notabh 
in  the  last  case  by  pressure  from  the  overlying  flexor  tendons  of  the  forearm. 
In  pei-forating  wounds  made  by  the  modern  bullet,  the  positions  of  the 
entrance  and  exit  wounds  and  the  symptoms,  together  with  experiments 
upon  dead  bodies,  show  that  the  bullet  almost  iuAariably  takes  a  direct 
course  through  the  part  hit,  irres])ective  <if  the  tissues,  be  they  soft  parts  or 
bonci  which  may  lie  in  its  course. 

30 


PLATE  II 


6idi 


PLATE  II. 

Lodg-ed  ^liiuser  l)idlets  (natural  size),  removed  from  S]ianisli-Aiiu'ric;m 
war  cases  after  having  been  located  by  the  Rontgen  ray.  All  the  hullets, 
except  No.  1,  show  deformity  due  to  ricochet  impact. 


PLATE  II. 


TMt  MEL'CTVPE  PRINTpNG  CO..  BOSTON. 


LODGED  MISSILES.  31 

In  l)iillets  wliicli  penetrate  onl}',  the  important  fact  that  tliey  also, 
almost  invariably,  pursue  a  direct  course  until  they  come  to  rest  is  clearh- 
demonstrated  by  the  position  in  which  they  have  been  located  by  the 
Rcintgen  ray.  Thus  in  Case  11,  Section  IV,  though  the  bullet  entered  butt 
end  foremost,  it  })assed  in  a  direct  line  through  the  ulna  to  its  place  of 
lodgment  beneath  the  flexor  tendons  in  front  of  the  inner  condyle  of  the 
humerus.  This  direct  course  of  the  bullet  when  reversed  has  been  noted 
in  other  cases,  and  it  would  seem,  therefore,  that  the  direct  course  of  the 
modern  Inillet  through  the  tissues  must  be  mainly  due  to  its  great  sectional 
density  rather  than  the  shape  of  its  end.  It  is  this  property  which  gives 
it  relatively  great  inertia  even  with  lowered  velocity  and  causes  it  to  pass 
without  deflection  through  the  opposing  force  of  the  tissues  until  it  comes 
to  rest. 

In  experimental  trials  with  the  jacketed  projectile,  its  tendency  to 
produce  perforating  rather  than  penetrating  wounds  was  found  to  be  verv 
great.  Arguiug  from  this,  it  was  thought  that  the  number  of  lodged  bullets 
in  warfare  where  this  missile  was  used  would  be  few.  But  in  these  experi- 
ments the  bullet  impinged  against  the  part  without  previous  ricochet,  while 
in  warfare,  especially  where  the  firing  is  at  long  range  or  where  the  troops 
are  intrenched  or  are  sheltered  in  any  way,  wounds  from  ricochet  missiles 
are  exceedingly  common  and  largely  increase  the  niunber  of  lodged 
bullets.  Rontgen-ray  examination  of  cases  of  lodged  Mauser  bullets,  and 
the  deformed  condition  of  many  of  these  bullets  when  removed  by  opera- 
tion, indicate  that  lodgment  was  due  in  many  instances  to  the  velocity  of 
the  missiles  having  been  reduced  by  ricochet. 

As  stated  above,  the  high  velocity  of  the  compound  bullet,  its  small  size, 
and  great  sectional  density  cause  it  to  perforate  animal  tissues  rather  than 
penetrate  them,  unless  its  velocity  is  greatly  reduced.  At  the  same  time,  its 
liigh  velocity  gives  it  great  tendency  to  ricochet  for  considerable  distance 
and  yet  retain  sufficient  momentum  to  produce  penetrating  wounds.  The 
compound  bullet  is  very  resistant  to  deforming  violence;  yet,  that  it  can 
sustain  violent  ricochet  impact  and  still  retain  sufficient  velocity  to  cause 
penetrating  wounds,  is  shown  by  the  great  deformity  of  some  lodged  bullets 
(Plate  II). 

In  determining  the  cause  which  has  so  lowered  the  velocitv  of  a 
small  caliber  projectile  that  it  has  lodged  in  a  part,  instead  of  i)erforating 
it,  evidence  is  either  presumptive  oi-  positive.  The  evidence  of  having 
struck  some  resistant  object  before  entering  the  body,  may  be  considered 
positive,  when  the  bullet  is  deformed,  especially  if  the  deformation  is  marked, 


32  RONTGEN  ray  in  SPANISH-AMERICAN  WAR. 

as  was  the  case  with  many  deformed  bullets,  in  cases  reported  in  the  late 
war.  It  is  stated  by  some  observers  that  the  modern  Vmllet  may  be  deformed 
1)V  impact  with  bone.  The  writer  is  inclined  to  believe  this  doubtful,  as 
the  bullet  is  relatively  so  much  more  resistant  than  osseous  tissue  it  hardly 
seems  possible  that  bone  could  otiter  sufficient  resistance  to  deform  it.  In 
any  event,  the  deformation  would  be  slight,  and  the  fact  should  be  con- 
sidered that  the  bullet  might  liave  struck  some  object  before  entering  the 
body  and  that  the  first  obstacle  and  not  bone,  had  deformed  the  missile. 

When  a  l(,>dged  missile  is  undeformed,  it  may  or  may  not  have  struck 
some  object  before  producing  the  penetrathig  wound  If  the  wound  was 
received  at  extremely  long  range,  the  evidence  is  presumptive  that  the 
lowered  velocity  of  the  ball  was  due  to  the  length  of  its  flight,  ^yhen,  how- 
ever, the  range  is  short  or  indcnown,  it  is  impossible  to  say  whether  lodge- 
ment was  caused  by  decreased  velocity  from  unknown  long  range,  t>r  from 
the  bullet  at  short  range  having  passed  through  some  obstacle  whit-h 
lowered  its  velocity  witliout  altering  its  shape.  For,  while  the  jacketed 
bullet  is  frequently  deformed  by  ricochet,  its  resistance  to  deformation  is  so 
gi'eat  that  in  many  cases  where  it  produces  penetrating  wounds,  it  is  C[uite 
reasonable  to  suppose  that  it  may  have  impinged  against  objects  not 
sufficiently  dense  to  deform  it,  or  even  may  have  passed  through  trees  or 
wooden  obstacles,  for  it  is  known  that  the  jacketed  bullet  will  pass  through 
many  inches  of  hnrd  wood  without  becoming  deformed.  In  cases  of 
penetrating  wounds,  where  the  lodged  bullets  are  undeformed,  it  is  fair  to 
suppose  that  quite  a  percentage  of  these  wounds  are  due  to  lowered 
velocity  from  causes,  such  as  those  given  above. 

In  the  Santiago  campaign,  the  large  number  of  lodged  missiles  was 
commented  on  by  the  surgeons.  In  198  Mauser  bullet  wounds,  seen  by  the 
writer,  there  were  "21  lodged  bullets.  This  number  is  unusually  high,  but 
serves  to  show  that,  imder  certain  conditions,  quite  a  number  of  lodged 
missiles  maj^  be  expected.  At  Santiago,  many  wounds  were  received  at 
long  range  and  in  a  wooded  terraine.  It  is  quite  })ossible  that,  in  some 
cases,  the  velocity  of  the  bullets  was  reduced  by  passage  through  the 
brandies  of  trees,  in  which  event,  from  the  resistance  of  the  1)ullet  to 
deforming  violence,  its  velocity  might  be  lowered  and  the  bullet  not  be 
deformed. 

Where  the  bullet  is  lodged  butt  end  foremost  in  the  tissues,  it  is  to  be 
concluded  that  the  ball  has  ricocheted  and  turned  end  for  end  before  strik- 
ing the  part.  The  fact  that  quite  a  number  of  bullets  were  found  lodged 
butt  end  foremost,  and  that  so  many  lodged  missiles  showed  deformation 


PLATE   III. 


PLATE  III. 

Case  1,  Section  II. — Ralph  Barkman,  j)nvate,  Company  K,  Second 
Massachusetts  Vokmteer  Infantry. 

Kadiograjili  of  left  leg,  viewed  from  the  inner  side,  showing-  deformed, 
Mauser  bullet  lodged  behind  the  tibia. 


PLATE  III. 


L0DGP:D.  MAUSER  BULLETS.  33 

produced  b^^  ricochet,  demonstrates  the  property  this  biilU^t  lias  of  retainino- 
sufficient  momentum  to  produce  penetrating  wounds  after  ricochet  impact. 
Wliile,  tlierefore,  under  conthtions  of  direct  impact,  tlie  small  size  and  great 
s(H'tional  density  of  tlie  small-caliber  jacketed  bullet  cause  it  to  produce 
perforating  wounds,  except  at  extremely  long  range,  so  raising  the  percent- 
age of  perforating  to  jjenetrating  wounds  which  it  is  liable  to  inflict,  relative 
to  these  percentages  compared  with  similar  wounds  made  by  the  older  lead 
bullet  of  lai-g(^  caliber;  the  ricocheting  property  of  the  modern  j)rojectile, 
which  is  greatly  in  excess  of  that  of  the  old  bullet,  increases  the  j)ropor- 
tionate  number  of  penetrating  wounds  which  it  is  liable  to  inflict  in  actual 
warfare.  This  ricocheting  property  of  the  compound  bullet  and  its  ability 
to  produce  penetrating  wounds  after  ricochet,  as  well  as  after  having  its 
velocity  re(Uiced  in  other  ways,  accounts  for  the  fact  that  the  numl)er  of 
cases  of  lodged  bullets  was  greater  in  the  late  war  than  was  anticipated 
from  experimental  trials  of  the  bullet  made  ])revious  to  its  use  under  actual 
conditions  of  warfare. 

DEFORMED,   LODGED,   MAUSER  BULLETS. 

In  the  two  following  cases,  the  first  illustrates  the  direct  course  of  a 
bullet  wliicli  has  been  blunted  at  tiie  point  by  impact  with  some  object 
before  entering  the  body,  but  without  materially  lessening  its  sectional 
densit\',  and  both  cases  illustrate  the  noninfection  of  wounds  b}'  deformed 
bullets. 

Cnac  1. — Deformed^  Mmmcr  hiiUct  Iixh/cd  in.  leg;  aseptic  wound;  localizatiouhy 
Rdntgtm  ray;  removal. 

Riilph  l)iirkniiin,  private,  Company  K,  Second  Massachusetts  Vohuiteer  Infantry, 
wounded  July  1.  1.S98,  l)y  two  bullets,  one  of  which  passed  through  the  loft  arm,  shat- 
tering the  liunierus;  the  other  entered  the  left  leg,  at  the  outer  surface,  upper  third, 
and  lodged.  The  patient  was  transferred  from  the  field  hospital  to  the  Relief.,  whei'e 
Rontgen  examination  located  the  bullet  behind  the  tibia,  8  inches  above  the  ankle 
joint  (Plate  III).  The  bullet  was  removed  and  it  (No.  4,  Phite  II)  and  the  radiograph 
show  that  the  missile  had  been  blunted  at  the  point,  from  impact  with  some  other 
object,  before  entering  the  leg.  The  wound  of  entrance  was  small  and  not  infected. 
There  was  marked  discoloration  of  the  skin  from  the  entrance  wound  downward, 
by  which  the  course  of  the  bullet  could  easily  be  traced. — ('(Lfe  report  compiled  from 
reeordu  In  Hu:r(jeon-  OeneraV H  Office. 

Caxe2. — Defcmned.,  MaM.^er  hidlet  lodged  in  thigh;  (inepfic  n'oimd;  local ization 
hy  Rwitgex  ray;  removal. 

Augustus  Snoten,  private,  Company  C,  Twenty-fourth  United  States  Infantry, 
wounded  July  1,  1898,  by  a  Mauser  Itullet,  whicli  enter(Ml  at  the  anterior  and  outer 


34  KONTGEN  ray  in  SPANISH-AMERICAN  AVAR. 

surface,  uiiddlo  third,  right  thigh.  The  patient  was  transferred  to  the  Relief,  where 
a  nmch-defornied  bullet  was  located  by  Rontgen  ray,  partially  behind  the  femur, 
some  distani'C  lower  down  the  limb.  It  was  removed,  when  it  was  found  to  1)(>  greatly 
deformed  from  lateral  impact,  the  casing  being  split  and  the  body  of  tlie  bullet 
concaved  and  flattened  (Plate  II,  No.  5.). 

The  wound  of  entrance  was  small  and  uninfected  and,  despite  the  deformed 
mi.ssileby  which  it  had  been  made,  presented  nothing  in  appearance  ditierent  from  an 
entrance  wound  made  by  an  undeformed  liullet. — Cme  report  compiled  from  reeonls 
in  6' urgeo7i,- Genera fx  Office. 

It  would  be  supposed  that  bullets  which  had  struck  other  objects  and  had 
been  det'oriued  before  euterino-  the  body,  would,  from  their  jag-g-ed  and 
irregular  form  and  lowered  velocity,  be  more  likely  to  carry  infection  into 
a  wound  than  undeformed  bullets  which  struck  the  body  without  ha\'ino- 
ricocheted.  There  are,  however,  but  two  cases  reported  of  infection  by 
deformed  Mauser  bullets,  though  probably  many  others  occurred.  The  fact 
that  so  few  cases  of  infection  were  reported,  as  arising  in  this  way,  tends  to 
show  that  infection  so  caused,  is  not  as  common  as  would  be  supposed.  In 
one  of  the  infected  cases  reported,  the  large  size  of  the  wound  and  its 
location  in  the  sole  of  the  foot  would  make  it  ])articularly  liable  to  infection. 
In  tlie  other  case,  the  bullet  was  greatly  deformed  and  had  lodged  very 
superticially. 

Case  3. — Deformed,  Mamer  hnilet  lodged  superficially  in  hnce;  woviid  slightly 
infected;  Realisation  iy  Rontgen  ray;  removal. 

Samuel  Davis,  private.  Company  L,  First  ITnited  States  Volunteer  Infantry, 
wounded  July  1  by  a  ricochet  ball,  which  entered  and  lodg(;d  superticially.  behind 
the  internal  condyle  of  the  left  femur.  The  patient  was  transferred  to  the  Rdief 
and  the  bullet  (No.  7.  Plate  II),  the  whole  point  of  which  had  been  carried  away  by 
ricochet,  was  located  (IMate  IV)  by  the  Rontgen  ray  and  removed.  The  wound  of 
entrance  was  infected,  but  healed  readily  under  antiseptic  dressings.  —  Case  rejaort 
compiled  from  records  in  Surgeon-  OeneraVs  Office. 

Case  If.. — Deformed,  Maimer  hvUet  lodged  in  foot;  septic  wound;  localisation  hy 
Rontgen  ray;  remmnil. 

John  N.  Taylor,  private,  Company  B,  Twelfth  Ignited  States  Infantry,  was 
wounded  July  1  by  a  Mauser  bullet,  which  passed  through  the  sole  of  his  shoe  and 
entered  the  bottom  of  the  left  foot,  directly  below  the  arch.  The  wound  was  (juite 
large  and  irregular  in  shape  and,  on  that  account,  was  thought  to  have  been  made  by 
a  fragment  of  shell,  until  the  ROntgen  ray  disclosed  a  Mauser  bullet,  with  an 
indentation  near  the  point,  lying  directly  beneath  the  cuboid  bone,  in  a  line  with  the 
.second  metatarsal  bone  (Plate  XIII).  The  wound  was  infected  and  suppuration  set 
in.  The  patient  was  transferred  to  the  Rdief  and  then  to  Washington  Barracks, 
D.  C,  where  the  bullet  was  removed  December  26,  1898,  and  the  patient  returned  to 
dutv  shortlv  afterward. 


PLATE   IV. 


PLATE  IV. 

Case  3,  Section  II. — Samuel  Davis,  private.  Company  L,  First 
U.  S.  Volunteer  Cavalry. 

Radiograph  of  left  knee,^^e■wed  from  the  inner  .side,  showing  a  Mauser 
biiUet,  deformed  by  ricochet,  lodged  behind  tlie  internal  condyle.  As  the 
radiograph  was  taken  through  the  dressings,  a  pin  and  the  mottling  due  to 
the  iodoform  gauze  are  also  showu. 


PLATE  IV. 


•  J)i'tbrf//t'd  Matisii'r  huilet 


-lodolovjii  tji/iau 


THE  HELIOTVPE  PRINTING  CO..  BOSTON. 


L0DGP:D,  MArSEK  BULLETS. 


35 


LODGED,  UNDEFORMED.  MAUSER  BULLETS. 

From  its  ivsistauce  to  extcnuil  violence,  the  compound  bullet  is 
probably  frequently  ricocheted  without  Ijecomuif;'  deformed.  In  mauj^ 
cases,  the  bullet,  from  its  irregularity  of  flight,  may  produce  extremely 
jaggeil  wounds,  as  in  the  case  next  given,  or  may  enter  the  l)ody  butt  end 
first,  and  the  radiograph  or  extraction,  alone,  show  that  ricochet  had 
occurred. 

Cased. — Maimer  hullvt  lodged  in  chest;  fractun'  <if  chiDicle;  lacerated.,  septic 
wound;  localization  hy  Rontgen  ray;-  bullet  not  removed. 

John  R.  Keen,  private,  Troop  L,  First  United  States  Volunteer  Cavalry,  was 
wounded  June  ^4,  ))y  a  Mauser  bullet,  which  entered  over  the  clavicle  at  the  junction 
of  its  outer  and  middle  thirds.  No  wound  of 
exit.  The  entrance  wound  was  about  3  inches 
long  and  so  lacerated,  that  it  was  thought  that 
the  injury  had  been  done  by  a  fragment  of  a 
shell.  The  patient  was  transferred  to  the  gen- 
eral hospital.  Key  West,  Fla.,  where  fluoro- 
scopic examination  showed  a  Mauser  bullet 
just  back  of  the  left  border  of  the  sternum  at 
the  second  intercostal  space,  lying  at  an  angle 
to  the  line  of  entrance  (hg.  8). 

The  large  size  and  larceration  of  the  ex- 
ternal wound  indicated  that  the  Itall  had  rico- 
cheted and  had  struck  the  body  while  oscillat- 
ing or  while  turning  on  its  long  axis.  As  the 
clavicle  was  badly  shattered  and  the  wound 
much  inflamed  and  suppurating,  the  wound 
was  thoroughly  cleansed  under  anaesthesia  and 
all  loose  fragments  of  bone  i-emoved.  The 
wound  healed  very  slowly  and  a  small  sinus 
still  existed  when  the  patient  was  transferred 
to  New  York,  August  23.  There  he  was  ad- 
mitted to  the  Roosevelt  Hospital,  where  Dr. 
Robert  Abbe  took  a  radiograph,  which  located 

the  bullet.  The  patient  was  an;esthetized,  the  wound  thoroughly  cleansed,  and  the 
bullet  searched  for  with  a  telephonic  probe,  passed  through  the  front  wall  of  the 
thorax,  3  or  i  inches  deep,  twenty  or  thirty  times  in  the  location  of  the  bullet,  as 
shown  l)y  the  radiograph,  but  no  result  was  obtained.  In  repoiting  the  case,  Dr. 
A))be  gives  his  opinion,  as  a  result  of  his  trial  of  the  telephonic  probe,  that  it  is  unre- 
liable. aTid  can  not  be  compared  with  the  Rontgen  ray  for  locating  lodged  missiles. 

The  following  cases  illustrate  displacement  of  the  bullet  from  the  line 
of  its  course,  either  from  pressure  of  neighboring  tissues,  or  from  muscular 
iiction,  or  from  imj)iiigement   of  the  missile  agahist  some  resistant   tissue 


■■:■::■■/  ■■•■   W.--.. 

W    i   '^•> 


■'"V 


Fig.  3. — Course  and  location  of  bullet  in 
case  of  Private  John  R.  Keen,  Troop  L, 
First  United  States  Volunteer  Cavalry. 


PLATE  V. 

Case  6,  Section  II. — Willimu  A.  Cooper,  private,  Company  A,  Tenth 
United  States  Ca\alry. 

Radiograph  sliowing  imdet'ornied  Mauser  bullet  lodged  in  right  thigh. 
The  vii'w  is  from  the  posterior  surface  mid  the  bullet  lies  at  nearly  a  right 
aua'le  to  its  line  of  entrance. 


PLATE  V. 


TltC  MEL:0TVPE  PftlNDNG  CO..   BOSTON 


PLATE  VT. 

Lodged  slirapnel  bullets  (natural  size),  located  by  the  Rontgen  ray  and 
removed  by  operation.  These  bullets  show  slight  deformation,  probably 
produced  at  the  time  of  explosion  of  the  case  in  which  thev  were  contained, 
and  not  due  to  ricochet.  From  the  low  velocity  of  the  shrapnel  ball,  it 
probably  seldom  ricochets  with  sufficient  force  to  jjroduce  jienetrating 
wounds. 


PLATE   VI. 


0       0 


• 


THt  MCtlOTVPf  PRINTING  CO.    BOSTON 


LODGED,  SHRAPNEL  BULLETS.  37 

LODGED,     -SHRAPNEL    HULLETS. 

The  shrapnel  l)u]let,  used  1a'  the  Spaniards,  was  a  round,  soft  lead 
bullet,  nieasurinji'  1.25  centimeters  in  diameter,  and  weighing-  a  little  over 
1 1  .ii-rains.      (Plate  VI.) 

As  the  velocit)'  of  these  bullets  is  <>uly  that  of  the  bursting'  charge  of 
the  shrapnel,  plus  some  of  the  initial  velocity  of  the  shell,  their  velocity 
is  comparatively  low,  and  these  missiles  belong  to  the  large  caliber,  low 
velocity  type.  Theoretically,  wounds  i)roduced  by  these  missiles  should 
differ  materialh'  from  those  produced  ]}x  the  small-caliber  bullet.  Practi- 
cally, there  was  not  so  marked  a  dift'erence  as  would  have  been  expected, 
for,  in  the  reported  cases,  the  woinids  which  had  been  given  a  primarv  dress- 
ing with  the  tirst-aid  packet  generally  healed  as  readih'  as  thos(i  made  by 
the  Mauser  bullet.  Also,  i'e[)orted  cases  show  that  in  many  instances,  neither 
by  the  appearance  of  the  entrance  wound  or  the  sensation  of  the  wounded 
man,  could  the  nature  of  the  missile  be  determined.  In  consequence,  many 
cases  of  penetrating  wounds  by  shrapnel  bullets  were  thought  to  have 
been  made  by  Mauser  bullets,  until  the  Rontgen  ray  or  removal  of  the 
missiles  showed  them  to  be  shrapnel. 

These  cases  ai"e  of  s])ecial  clinical  value,  as  they  show  that  wounds 
made  by  the  larger  lead  bullets,  when  luiiuterfered  with  and  treated  by 
occlusive  dressings,  are  usually  asejttic  and  I'un  favorable  courses. 


7. — Shrapiwl  haU  lodged  in  m'fh;  nxcptic  iroii))d ;  Uic(d>zati.(>n  hy  Riintgen 
ray;  removal. 

George  A.  Harper,  private.  Conipaii}'  E,  Thirteenth  United  States  hifantry, 
was  woiuided  July  1,  by  a  shrapnel  ))all  which  entered  the  back  of  the  nei'k,  half  an 
inch  to  the  left  of  the  second  cervical  spine.  The  wound  was  dre.ssed  with  the  tirst- 
aid  packet  and  the  patient  was  transferred  by  the  steamer  Troqw/is  to  the  general 
hospital.  Key  West,  Fla.  When  admitted  to  the  hospital,  the  wound  of  entrance 
was  aseptic  and  so  .small  that  there  was  nothing  to  indicate  that  it  had  been  made 
by  other  than  a  Mauser  bullet,  and  the  patient  himself  believed  that  he  hud  been 
wounded  by  that  missile. 

The  fluoroscope,  however,  showed  that  it  was  a  shrapnel  l)idl,  and  it  was  removed 
July  It),  from  beneath  the  anterior  edge  of  the  sterno-mastoid  muscle,  2  inches 
below  the  lower  end  of  the  mastoid  process.  Though  made  by  a  shrapnel,  the 
wound  track  was  not  infected,  the  wound  of  operation  healed  by  first  intention,  and 
the  patient  was  well  when  furloughed  August  (>. 

(JaseS. — Shrapnel  hall  lodijed  in  liach  :  aseptic  ino'wn<l, ;  local izailon  hy  liihdyen 
rajy ;  removal. 

Henry  E.  C'onover,  private.  C-ompany  E,  Ninth  United  States  hifantry,  was 
wounded  in  the  left  shoulder  July  1,  the  bullet  entering  I  inch  above  the  clavicle,  at 
6648 4 


352528 


38 


liONTGEX  KAY  IN  SPANISH-AMERICAN  WAR. 


Fici.  J>. — Diagram  explana- 
tory of  I'latc  VII,  showing 
lixmtioii  of  shraptu'l  Imllet, 
'I,  in  the  case  of  Private 
Henry  E.  Conover,  Com- 
jiany  E,  Nintli  Tuited 
States  Infantry. 


the  juiictioii  of  the  outer  and  middle  thirds  of  the  hone. 
The  wound  was  dros.sed  with  the  tirst-aid  dressing-  and  the 
jKitient  was  transferred  to  the  g-eneral  hospital.  Key  West. 
Fia..  where  tiuoroseopie  examination  was  made,  but  the 
liuUet  eoidd  not  he  located.  A  statie  machine  was  used  at 
Key  West,  and,  owing  to  the  great  humidity  of  the  air  at 
that  place,  the  apparatus  failed  to  produce  sufficient  light 
to  penetrate  the  thicker  parts  of  the  hotly.  For  that  rea- 
son, lodged  bull(>ts  t'ould  not  be  located  in  some  cases 
while  at  that  hospital. 

On  admission  to  the  hospititl,  tht'  wound  was  small 
and  aseptic,  healed  (]iiickly,  and  from  its  appearance  it  was 
thought  to  have  been  made  by  a  small-caliber  bullet.  The 
patient  complained  of  pain  in  the  region  of  the  shoulder 
blade,  but  had  no  other  symptoms.  He  was  furloughed 
August  t).  but  on  rejoining  his  regiment  at  the  expira- 
tion of  his  furlough  he  found  it  difficult  to  handle  a  gun, 
and  was  sent  to  the  general  hospital  at  Washington  Bar- 
racks, D.  C.  The  bitllet  was  located  just  beneath  the  pos- 
scapula.     The  radiograph  showed  it  to  be  a  shrapnel  (Plate 


terior  border  of  the  left 
VII  and  tig.  5). 

The  bullet  was  removed  D(>cemt)er  8.  llSiiS.  the  wound  healed  by  rii-st  intention, 
and  the  patient  returned  to  duty  six  days  later.  In  this  case  the  woiuid,  though 
made  by  a  shrapnel,  was  entirely  aseptic  and  remained  so  luitil  the  bullet  was 
removed,  tixc  months  after  receipt  of  the  injury.  .Vt  the  operation,  the  tissue  about 
the  bullet  wound  showed  no  evidence  of  inflammation,  and  the  bullet  was  producing 
trouble  only  through  friction  in  movements  of  the 
shoulder. 

Oai<e  9. — -Shrapiii'l  Indict  v^ound  left  (/rolii  ; 
aneptic  wound;  localhat'um  hy  Mdntgen  ray ;  re- 
moval. 

.Teremiah  Butler,  corporal.  Company  C,  Six- 
teenth United  States  Infantry,  was  wounded  July 
1,  by  a  bullet,  which  entered  the  groin  2  inches  to 
the  left  of  the  root  of  the  penis.  From  the  appear- 
ance of  the  wound,  the  bullet  was  thought  to  have 
been  a  Maaser  and  the  wound  was  dressed  with  tte 
first-aid  dressing.  The  patient  was  sent  from  San- 
tiago to  Fort  McPherson,  Ga..  where,  by  examina- 
tion with  the  fluoroscope.  the  Indlet  was  located 
deep  in  the  left  thigh,  about  ;i  inches  below  the 
lesser  trochanter.  As  the  examination  could  be 
made  only  from  before  backward,  the  round  shadow 
thrown  by  the  ball  caused  the  examiner  to  think 
the  bullet   a   Mauser   lying   end   on.      Afterwards, 


Fig.  (i. — liiagrani  explanatory  of 
Plate  VIII,  showing  location  of 
bullet  in  the  ease  of  Jeremiah 
Butler,  eorporal  Company  C,  Six- 
teentli  United  States  Infantry. 


PLATE   Til. 


PLATE  VII. 

Case  8,  Section  II  — Henry  E.  Couover,  private,  Company  E,  Ninth 
United  States  Infantry. 

Radiograpli  of  the  left  shoulder,  viewed  from  the  back,  showinji' 
shrapnel  hullet  lodged  just  behind  the  internal  border  of  the  scapula. 


PLATE  VII. 


THE    HEUOTVPE   PHINTIMG   CO..    BOSTON. 


PLATE  VIII. 


PLATE  VTTI. 

Cask  I),  Section  II. — Jereiuiuh  Butler,  cdrpdnil,  ("(Pinpany  C,  8ixteentli 
United  States  Infantry. 

RacUogra|)li  of  left  tliigli,  viewed  from  the  })Osterior  surface,  Rliowing 
shrapnel  bullet  lodged  deeply  in  the  thigh  about  3  inches  below  the  lesser 
trochanter.  The  deep  location  of  the  ball  is  indicated  by  its  dimness  of 
outline  and  the  lack  of  contrast  between  it  and  the  surrounding  parts. 


PLATE  Vlll. 


THL  HELIOTYPE  PRINTING  CO..  BOSTON. 


L0D(;EI).  BRA8S-JACKKTKI)  lU'LLPrrs.  39 

the  patient  was  transferred  to  the  general  hospital.  Washington  Barracks,  D.  C. 
On  admission,  there  was  no  evidence  of  inflammation,  but  the  patient  complained  of 
pain  extt'uding  down  the  limb,  and  he  walked  with  a  limp.  A  radiograph  was 
taken,  which  showed  the   bullet  to  be  a  shrapnel  (Plate  VIII  and  tig.  6). 

In  the  operation  for  removal  the  bullet  was  found  em))edded  in  the  tissues  in 
close  proximity  to  the  sciatic  nerve,  thus  explaining  the  pain  and  disability.  The 
patient  recovered  without  event  and  was  returned  to  duty  a  few  days  after  operation. 

When  subjected  to  operative  treatiuent  in  the  hehl  hospitals  under  con- 
ditions not  strictly  aseptic,  wounds  l>y  the  sln-apnel,  like  tliose  by  other 
missiles,  generally  become  infected. 

Case  10. — Shrapnel,  ball  Uxk/ed  In  axilla;  h^diukI  i.vplorciL  at  jiiUl  lidxpiial :  si/j>- 
jmratimi;  localization  hy  Rontgen  ray;  removal. 

Patrick  McDonnell,  private.  Company  F,  Sixteenth  United  States  Infantry, 
was  wounded  July  1,  by  a  shrapnel  l)ullet  which  enteied  2  inches  below  the  right 
acromion  process.  No  wound  (jf  exit.  An  unsuccessful  attempt  was  made  in  the 
field  hospital  to  remove  the  bullet.  Suppuration  occurred,  and  an  incision  for  drain- 
age was  made.  The  patient  was  transferred  to  Fort  McPherson,  thence  to  the 
general  hospital,  Washington  Barracks,  D.  C.  Suppuration  ceased  and  the  wound 
healed.  Radiograph  di.sclosed  bullet  Ij'ing  in  the  axilla  beneath  the  nei'k  of  the 
scapula.  Operation,  under  ether,  December  7,  the  bulk^t  removed.  Wound  healed 
by  first  intention  and    patient  returned  to  duty  January  ^6,  1891>. 

Cane  11. — Sltra^inel  hall  Imlgi-d  i^aperlicially ;  xeptlc  wound;  localization  hy 
Rontgen  ray;  rein,<ival. 

William  T.  Earle,  private,  Company  (t.  Sixth  United  States  Cavalry,  wounded 
July  1,  by  a  shrapnel,  which  entered  and  lodged  just  above  the  superior  iliac  spine, 
leftside.  The  wound  was  dressed  and  the  patient  transferred  to  the  Relief.  Radio- 
graph showed  bullet  lodged  just  above  point  of  entrani'e.  The  wound  was  probably 
infected,  for  slight  suppuration  and  necrosis  of  the  ilium  was  noticed  at  the  Long 
Island  College  Hospital,  where  the  patient  was  transferred  from  the  Relief.  The 
wound  eventually  healed  and  the  patient  was  returned  to  duty.  —  (Ja^^e  report  compiled 
from  recordti  if  Surgeo'n-  GeneraVs  Office. 

LODGED,  BRASS-JACKETED  BULLETS. 

The  Spanish  regular  troops  were  armed  exclusively  with  the  Mauser, 
but  some  of  the  irregidar  troops  were  armed  with  the  Remington  of  .41 
caliber,  carrying  a  bullet  havmg  a  brass  jacket  and  soft  lead  core.  This 
bullet  was  easily  deformed,  the  jacket  Ijeing  nuich  less  resistant  to 
deforming  violence  than  the  nickel-steel  jacket  of  the  Mauser  (Plate  IX). 

In  consequence  of  its  large  size  and  deformability,  this  missile 
frequently  produced  wounds  of  considei'able  size — wounds  either  originally 
infected  or  extremely  liable  to  become  so. 


40  KOMUE.N   KAV  IN  SPAMSll-A.MKHlCA^  WAK. 

A  sufficient  number  of  Rrmtgen-ray  cases  f»t"  Avounds  bv  this  l)ullet 
were  not  re])orte(l  to  enable  any  general  conclusions  to  be  drawn  relatixe 
to  its  action  when  penetrating.  The  cases  reported  were  infected  and  their 
liistories  are  given  under  Cases  13,  and  14,  Sectiou  IV,  and  Case  5,  Section  V. 

INJURIES    TO    THE     CENTRAL     NERVOUS     SYSTEM     BY     PENE- 
TRATING MAUSER   BULLETS. 

In  gunsliot  injury  of  the  spinal  cord  or  l)rain,  where  the  l)ullet  is 
lodged,  it  becomes  important  to  ascertain  whether  tlie  symptoms  are  due 
to  the  original  traumatism  or  to  pressure  from  the  ball.  In  the  late  war,  but 
tlu'ee  cases  where  the  Rontgen  ray  was  used  were  reported  which  vnnw 
under  this  class,  but  these  cases  were  of  marked  clinical  interest. 

Two  of  these  cases  were  of  injury  to  the  spinal  cord,  and  in  one,  the  brain 
w^as  wounded.  In  the  cord  cases,  localization  of  the  embedded  l)nllets  liy 
Rontgen  ray  demonstrated  that  the  symptoms  were  due  to  the  original 
traumatism  and  not  to  the  presence  of  the  Inillet.  The  brain  case  is  of 
interest  from  the  full  history  which  is  given  of  the  patient's  condition,  the 
bullet  being  still  embedded  in  the  brain  at  the  time  the  report  was  rendered. 

C'(Ke  12. —  (runshof  injury  of  the  cord;  jiLn(,ser  IndUt  linlged  in  back;  localiza- 
tion hy  Rontgen  ray;  renioml;  discharge  for  disability. 

C.  James  Edwards,  private,  Hospital  Corps,  woiiuded  at  Malate,  Philippine 
l.slands,  July  31.  1S98.  Bullet  entered  at  a  point  over  the  middle  of  the  left  deltoid 
muscle,  opposite  the  surgii'ul  neck  of  the  humerus.  At  the  time  of  the  easualty,  the 
arm  was  deflected  from  the  thorax  at  an  angle  of  about  60  degrees.  There  was  no 
wound  of  exit.  Immediately  upon  receipt  of  the  injury,  the  patient  fell  to  the 
ground,  and  there  was  complete  paralysis,  involving  both  the  upper  and  lower 
extremities.  He  was  removed  to  the  hospital,  soon  became  unconscious  and  I'emained 
.^o  for  two  days.  There  was  no  discoverable  activ(>  hemorrhage  or  fracture.  Reflex 
functions,  .so  far  as  it  is  po.ssible  to  ascertain,  were  entirely  absent  below  that  portion  of 
the  spine  where  thl^  injury  was  suppt)sed  to  be.  Thei'e  was  rect^d  and  vesicle  paralysis. 
After  an  interval  of  three  weeks,  during  which  time  there  was  no  improvement,  he 
began  to  regain  conti'ol  of  his  arms.  A  progressive  change  for  the  better  was  inaugu- 
rated, followed  by  partial  restoration  of  power  oi  movement.  Complete  sensibility, 
both  as  to  pain  and  temperature,  returned  to  the  right  half  of  the  body.  He  was 
transferred  to  the  division  hospital,  Presidio,  San  Frant'isco,  t"al.,  October  22,  1898. 
At  that  time  he  was  able  to  walk,  but  with  great  dithculty.  On  his  arrival  at 
Presidio  there  was  a  loss  of  electro-contractility  as  to  setisil)ility  in  the  left  arm.  fore- 
arm and  hand,  left  half  of  the  thorax,  left  half  of  the  abdt)nieii  and  left  leg  and  foot. 
There  was  loss  of  sense  of  temperature  over  this  area.  Tactile  sense,  however, 
was  generally  present.  A  paitial  paralysis  of  the  sphincter  ani  and  vesicse  pei'sisted. 
Knee  jerk  increased   on   right  side,  feebly    present   on   left   side.     Motion  of   the 


PLATE    IX. 


PLATE  IX. 

Lodged,  brass-jacketed  bullets,  uattiral  size.      The  bullets  liave  been 
defcn-ined  1)\'  ricochet,  one  having  the  jacket  entirely  stripped  oii". 


PLATE  IX. 


^ 1 


# 


THt  HELIOTVPE  PRINTING  CO..   BOSTON. 


PLATE    X. 


PLATE  X. 

Case  12,  Section  II. — C  James  Edwards,  private.  Hospital  Corps. 

Radi()<)Taph  of  chest,  viewed  from  the  back,  showing  lodged  Mauser 
IniUet,  which  has  passed  through  the  sjiine,  lyiug  2  inches  to  the  right  of  the 
spine  over  tlic  tliii'd  intercostal  space. 


PLATE  X. 


GUNSHOT  OF  CENTRAL  NERVOUS  SYSTEM. 


41 


extremities  was  almost  completely  restoivrl.  Symptom.s  in  reference  to  the  brain, 
negative.  Sexiuii  povviM-  iind  desire  almost  nil.  No  ankle  clonus.  No  irreo-iilaritv 
in  any  of  the  internal  organs,  but  a  languid  and  sluggish  condition,  lacking  the 
power  of  vigorous  action. 

January  2,  18!)!t,  motion  now  only  slightly  iiuijuired  in  left  upper  and  h'ft  lower 
extremity.  Coordination  of  muscles  virtually  normal.  Power  of  nuisi-Ies  is  inhibited 
in  right  leg.  Electro-contractility  absent  in  the  left  lower  exti-emity.  extending  from 
the  crest  of  the  ilium  to  the  planter  surface  of  the  foot.  There  is  also  loss  of  the 
.sensation  of  temperature  over  this  area.  Sensibility  completely  alisent  in  the  left  leo- 
and  foot.  Mobility  ab.sent  in  the  left  foot.  Micturation  and  defecation  disturbances 
are  still  present.  Sexual  power  is  diminished,  but  desire  is  normal.  As  far  as  he 
can  remember  there  has  been  a  constant  dull  pain  iri  the  back,  in  the  reo-ion  of  the 
third  intercostal  .space,  an  inch  and  one  half  to  tiie  right  of  the  spinous  process  of  the 
third  dorsal  Aertebra.  Radiograph  (Plate  X) 
shows  a  lodg(>d  Mausei'  bidlet  at  the  point 
where  the  pain  at)ove  mentioned  exists.  Bul- 
let was  extract(^d  March  7.  1899,  and  as  the 
patient  remained  disqualified  for  military 
service,  he  was  finally  discharged  on  account 
of  impairment  of  mobility  of  right  leg  and 
thigh,  and  loss  of  .sense  and  contraction  of 
the  left  leg.  —  Case  reported  hy  Maj.  W.  A'. 
H.  MatthmcK,  Svrgmn,  TJ.  S.   Vols. 

In  the  followiiio'  case,  spinal  injur>' 
was  caused  by  depressed  fragments  of 
bone.  Localization  of  the  bullet  showed 
that  the  inissile  was  producing  no  ill  ef- 
fect in  the  tissue.  T.,aminectomy  was 
done  and  recovery  followed.  The  posi- 
tion of  the  bullet,  butt  end  foremost  in 
the  tissues,  makes  it  ])rol)able  that  the 
missile  had  ricocheted  before  entering 
the  body. 


/ 


•a 

Fid.  7. — DiajJiram  sliouiiific  wouml  nl  entrance, 
<i,  ami  position  of  bullet,  //,  in  the  cai^e  of 
Edward  Marshall. 


Can'i  13. — Edward  Marshall,  reporter,  wounded  at  La  Quasimas,  Jul_v  ^-i,  by 
Maaser  bullet,  which  entered  the  back,  1  inch  to  the  left  of  the  spine  at  level  with 
the  sacro-lumbar  articulation.  Complete  pai-alysis  of  the  lower  extremities  and  loss 
of  sensation  followed  the  receipt  of  the  injury.  Patient  was  transferred  north  on 
the  (>Ju'<4ti\  and  entered  the  Roosevelt  Hospital,  New  York  City,  where  he  came 
under  the  care  of  Dr.  Robert  Abbe.  Dr.  At>be  took  a  radiograph  of  the  case, 
which  located  the  missile  lying  butt  end  foremost.  1  inch  to  the  right  of  tlie  first 
lumbar  vertebra  and  deeply  placed  in  the  neighborhot)d  of  the  renal  vessels  (Fig.  7). 
'  The  position  of  the  bullet  precluded  the  possibility  that  the  .symptoms  were 
due  to  the  pressure  from  the  missile.     Dr.  Abbe  did  a  laniinectom}-  and  removed  al! 


42  HONTCIKN  KAY  IN  SPANISH-AMERICAN  WAR. 

depressed  frajJiiU'iits  of  hone   whioh  wtnv  pl■es!^ill^■  on  the  spinul  cord.     The  bullet 
was  not  i-eiiioved. 

The  next  case  i.s  of  interest,  in  that  it  sIkpws  the  result  of  a  gainshot 
wouikI  of  the  brain,  the  bullet  being'  unrenioved,  and  what  slight  disability 
and  how  few  inipoi'tant  or  disturbing  symptoms  ma\'  persist  as  a  result  of 
lodgement  of  a  small-caliber  liuUet  in  the  bi-ain. 

Canellf.. — Peni'traimij.  MaitxirhulUt  u^oioid ofhmln ;  irimnil as, jitic;  liullrt  imf  n  uini-rd. 

.John  (iretzer.  jr..  private.  Company  D.  First  Ncl)rask;i  \'oJunteer  Infantry, 
wounded  at  lono-  ranye.  March  27.  18!Mt.  at  ^larihoa.  Pliiiii)j)iiie  Islands,  hy  a  Mau.ser 
bullet  eiUerini;-  ca\ity  of  iTaniuni.  three-fourths  of  an  incii  abo\e  the  supraorl)ital  ridge 
and  one-fourth  of  an  inch  to  the  left  of  the  median  line.  There  was  total  k)ss  of 
eon.sciousness  during  first  few  hours  following  receipt  of  the  traumatism,  with  the 
exception  of  a  few  short  intervals  of  .semiconsciousness,  at  which  time,  excruciating 
pain  in  the  head  was  experienced.  The  patient  was  taken  to  the  First  Reserve  Hos- 
pital at  Manila,  where  he  laid  in  bed  for  about  four  weeks.  While  in  bed,  he 
sutlered  extremely  from  pain  in  the  head,  most  severe  the  first  three  days,  moderat- 
ing slightly  at  the  end  of  the  iifth  week,  becoming  intermittent,  greatly  exaggerated 
on  exertion,  by  heat,  and  i^sjxH'ially  direct  rays  of  the  sun,  exposure  to  which  caused 
him  to  reel,  stagger,  and  almost  lose  consciousness.  At  the  present  time  (August, 
1899),  is  still  ijuite  su,sceptible  to  direct  rays  of  the  sun.  First  few  days  of  illne.ss 
were  marked  l)y  extreme  naus(>a  and  persistent  vomitiny;  the  slightest  thiny-  taken  in 
the  stomach  would  be  rejected.  The  pain  in  the  head  increased  the  severity  of  these 
attacks.  During  early,  weeks  of  ilhiess  any  exertion  of  the  brain,  as  reading,  caused 
])ain  in  l)ack  of  eyes  and  vertex  of  the  head. 

Returned  to  San  Francisco  with  his  regiment  in  August.  V6W.  Radiogi-aph 
taken  August  20,  showed  Mauser  bullet  eml)edded  in  left  oct-ipital  lobe  (Plate  XI). 
General  condition  good,  as  shown  by  photograi)h  (Fig;.  S). 

Condition.  Octol)er  1.  ItS'.tH,  six  months  aftei'  receipt  of  the  injury:  Occasionally 
has  pain  in  the  lumbar  region,  and  describes  it  as  being  a  "catch,"  lastmg  about  five 
minutes  at  a  time.  Pain  in  the  head,  when  pivsent,  is  located  a  little  anterit)r  to 
p:iiietal  eminence  on  left  side.  There  is  no  history-  of  loss  of  power  on  either  side, 
but  a  weakness  is  appreciated  in  the  right  arm  and  leg,  and  a  slowness  in  response 
to  miMital  impidse.  This  last  is  demon.strated  in  the  act  of  writing:  though  the 
thought  is  perfectly  clear,  there  is  a  slowness  in  the  forming  of  the  words. 

Voice :  Patient  did  not.  to  his  knowledge,  exercise  this  function  for  first  two 
days  of  illness,  but  on  beginning  to  do  so.  notic(?d  a  slight  confusion  of  ideas,  it 
being  necessary  to  Hrst  clearly  tix  a  thought  before  giving  expression.  There  was 
also  temporary  loss  of  power  to  recall  past  events  and  names  of  companions.  I'his 
returned  with  full  clearness  at  other  times.     A  slight  confusion  still  remains. 

Eye  :  Pain  back  of  left  eye  more  or  less  .severe,  and  increased  by  use,  and 
relieved  by  closing  the  lid.  During  continement  to  lied  following  injury,  patient 
tested  vision  of  left  eye  by  closing  right.  The  vision  was  clear,  but  slight  weakness 
and  jjhotophobia  was  noticed.     Ptosis  of  left  eye  was  marked  during  early  weeks  of 


PLATE    XI. 


PLATE  XI. 

Case  14,  Section  II. — Jolm  Gretzer,  jr.,  ))rivate,  Company  D,  First 
Nebraska  Volunteers. 

RadiogTaj)!!  of  head  viewed  from  the  left  side,  sliowiug  Mauser  bullet 
lodged  in  the  braiu. 


PLATE  XI. 


Jl^ 


s-  %  .i«i**  i*i| 


■'S*^#«*^' 


THE    HELIOTVPE    PRINTrNO   CO.,    BOSTON. 


GUNSHOT  OF  CENTRAL  NERVOUS  SYSTEM. 


43 


illness.  Aperture  is  now  sinaller  thiin  that  of  right  eye.  A  slight  diplopia  was  also 
present,  a  line  of  printing-  appearing  double.  Pupils  are  regular,  l)ut  left  slightly 
larger.  Reaction  to  light  and  power  of  aceonimodation  is  noticeably  decreased, 
especially  in  left  eye.     Visual  field  normal.     No  nystagmus. 

Hearing  is  normal.     Sense  of  smell  more  acute  on  right  side.     Sense  of  taste 
more  acute  on  right  side,  the  anterior  two-thirds  of  left  showing  marked  didlness. 


Fi(i.  8.— Photograph  of  Private  John  Gretzer,  jr.,  Company  D,  First  Nebraska  Volunteer  Infantry, 
taljen  live  months  after  receipt  of  injury.     Scar  of  wound  of  entrance  aliove  left  eye. 

Tactile  sense  seemingly  slightly  dull  on  right  side.     General  sensation  of  right  side 
not  as  acute  as  on  opposite  side. 

Reflexes:  Knee  reflex  very  marked  on  right  side,  n'sponding  to  touch  above,  as 
well  as  below  tiie  joint;  the  contact,  from  finger  causing  a  disagreeable  tingling 
throughout  the  thigh.     On  left  side,  reflex  is  exaggerated,  but  not  to  such  a  marked 
6648—5 


44  RONTGEN  RAY  IN  SPANISH-AMERICAN  WAR. 

extent.  Wrist  reflex  marked  on  i-ight  .side,  ca  's  ng  a  chronic  .spasmodic  contraction 
of  the  fingers,  and  the  hands  tingling.  Reflex  absent  on  left  side.  Ankle  clonus 
and  patellar  reflex  ab.sent.  Chreniaster'/J  marked  on  both  sides.  Sphincters 
uninvolved  at  any  period  of  illness ;  coordmauon  good,  though  a  slight  uncertainty 
is  felt  on  attempting  to  walk  with  the  eyes  closed.  No  epileptiform  seizures.  No 
disturbance  of  nutrition  or  ))odily  functions.  The  patient  afterwards  entered  the 
mail  service  and  returned  to  Manila  on  duty. — Reported  hy  Major  A.  C.  Girard, 
Surgeon,  United  States  Army. 

GENERAL    CONCLUSIONS    RELATIVE    TO     PENETRATING 

MISSILES. 

From  the  foregoing,  it  seems  reasonable  to  conclude  that  the  compound 
bullet  of  small  caliber  is  not  apt  to  lodge  in  the  tissues  unless  its  velocity 
has  been  greatly  reduced  by  long  range,  by  ricochet,  or  by  having  passed 
through  some  obstacle  before  entering  the  body. 

Relative  to  infection  of  the  wound,  it  would  seem  probable  that  missiles 
which  had  struck  some  other  object  before  entering  the  body  would  be  more 
liable  to  be  infected  and  to  produce  infected  wounds  than  those  which  had 
passed  tlu'ough  the  air  only;  and  that  the  small  caliber  bullet,  toward  the 
end  of  its  flight,  when  traveling  with  low  velocity,  would  be  extremely 
liable  to  can-y  foreign  matter,  shreds  of  clothing,  etc.,  into  the  wound  and 
so  infect  it.  In  fact,  that  all  bullets  which  lodge,  would  be  more  likely  to 
produce  infection  of  the  wound  than  bullets  which  have  sufficient  velocity 
to  pass  through  the  part.  It  appears,  however,  that  neither  ricochet,  jjassage 
through  other  objects,  or  lowered  velocity  nmrkedly  increases  the  proneness 
of  the  jacketed  missile  to  produce  infection.  This  is  of  clinical  importance 
in  that  the  lodgment  of  a  bullet  does  not  necessitate  the  treatment  of 
the  wound  which  it  has  made  as  though  it  were  an  infected  one.  It 
appears  that  such  wounds  are  best  treated  by  occlusive  dressings  and  non- 
interference, unless  manifestly  infected  or  some  special  condition  calls  for 
ojjeration.  It  further  appears  that  large  lead  bullets  of  low  velocity  are 
not  as  aj)t  to  make  infected  wounds  as  was  supposed,  and  that  the  same 
conclusions  as  to  treatment  hold  witli  them  as  with  the  modern,  jacketed 
projectile. 


III. 

THE     LOCALIZATION     OF    LODGED     MISSILES. 

THE    RONTGEN    RAY    AND    WOUND    EXPLORATION. 

The  superiority  of  the  Rontg-en  ray  over  other  methods  of  locating 
k)clged  missiles  is  so  great  that,  wlien  available,  it  should  be  used  to  the 
exclusion  of  all  others. 

It  is  a  most  distinct  aid  to  conservative  surgery,  in  that,  with  it 
obtainable,  disturbance  of  the  wound  through  immediate  attemjjts  to  locate 
missiles  is  usually  unnecessary.  Before  its  introduction,  it  was  frequently 
thought  recjuisite  to  follow,  or  attempt  to  follow,  the  track  of  the  bullet 
before  the  track  was  healed,  as  the  only  way  of  locating  a  missile  which 
might  produce  subsequent  trouble.  When  tlie  probe,  or  one  of  its 
substitutes,  is  used,  one  of  the  tenets  of  modern  military  surgery,  namely, 
noninterference,  can  not  be  followed,  and  septic  infection  is  made  possible 
or  probable.  With  the  Rontgeu  ray  at  hand,  the  surgeon  can  locate  a 
lodged  missile  at  any  time  when  necessity  demands,  and  its  track  can  safely 
be  left  undisturbed. 

The  unreliability  of  the  probe  for  locating  lodged  missiles  is  well 
known.  With  the  probe  it  is  p(»ssible  to  follow  only  a  small  minority  of 
bullet  tracks.  The  contractility  of  the  tissues  may  interpose  obstacles  to 
its  passage  and  a  change  of  position  on  the  part  of  the  patient  may  cause 
such  a  shifting  of  muscular  and  fascial  structure  as  to  completetely  obstruct 
or  alter  the  i)ath  made  by  the  projectile.  In  fact,  a  great  majority  of  cases, 
where  the  bullet  has  been  located  by  the  the  Eontgen  ray,  show  clearly 
how  impossible  it  would  have  been  to  determine  the  position  of  the  missile 
by  means  of  a  probe. 

Not  only  is  it  difficult  to  follow  the  path  of  the  bullet  with  a  probe, 
but,  even  having  done  so,  assurance  that  the  missile  has  been  touched  is 
often  impossible.  The  nickel-steel  jacket  of  the  modern  bullet  leaves  no 
mark  on  the  porcelain  tip  of  a  Nelaton  probe,  and  sensation  of  cont-^  ^c  as 
differentiated  between  a  missile  and  fibrous  tissue  is  not  sufficiently  definite 
to  enable  an  examiner  to  determine  that  the  probe  is  in  apposition  with  the 
bullet.  Nor  can  the  telephonic  probe  be  relied  upon;  as  is  shown  in  Case  5 
of  the  preceding  section. 

45 


4(3  RONTGEN  ray  in  SPANISH-AMERICAN  WAR. 

But  iidt  (lulv  is  the  probe  uureliablL',  but  it  is  a  source  of  danger,  even 
wlien  used  with  all  possible  aseptic  and  antiseptic  precautions.  The  experi- 
ments of  LaGarde,  Delornie,  Habart,  and  P^'aulhaber  liave  shown  that  in 
practical! V  all  bullet  wounds,  even  tliose  made  by  the  modern  comjxmnd 
l)ullet,  some  foreign  matter  and  bacteria  are  carried  into  the  wound.  The 
numl)er  of  bacteria  so  carried  in  are  usually  not  sutttcient  to  j)roduce 
sm'gical  infection  and  subsequent  inflammation  and  suppuration,  jjrovided,  the 
wounds  are  protected  from  further  infection  and  are  left  undisturbed.  For, 
undoulitedly,  the  factor  of  noninterfenence  with  the  wound  is  of  great 
importance.  No  sooner  is  a  traumatism  inflicted  than  natural  processes  are 
brouo'lit  into  action  for  protection  and  repair.  There  is  a  local  increase  in 
vascular  activitv,  serum  is  poured  out,  leucocytes  accumulate,  and  the 
defensi\'e  factors  of  })hagocvtosis  and  serum  bactericidal  action  are  brought 
into  plav.  That  these  factors  may  have  best  opj)ortunity  for  action,  rest 
and  nondistm-bance  of  the  tissue  are  necessary.  ]\Ieclianical  disturbance 
of  the  tissues  liy  probes,  by  the  finger,  or  by  instruments  will  produce 
fresh  traumatisms  and  cause  disturbance  of  the  defensive  action  going  on, 
and  these  trai;matisms  and  disturbances,  however  slight,  will  favor  growth 
of  the  bacteria  and  add  to  the  defensive  lahoY  required  of  the  tissues.  So 
that  even  aseptic  or  antiseptic  operative  or  explorative  interference  may 
tlu'ow  the  scale  on  the  side  of  the  invading  bacteria  and  lead  to  trouble- 
some or  disastrous  consequences.  For  these  reasons,  and  in  consideration 
of  tlie  unreliability  and  d;uiger  of  searching  for  a  bullet  through  the  ^^•ound, 
it  mav  be  stated  that  such  search  is  contraindicated,  except  in  cases  where 
the  innnediate  danger  from  the  presence  of  the  bullet  is  greater  than  the 
possible  consequences  wdiich  mav  anse  from  interference. 

Fortunately,  cases  re(iuiring  immediate  removal  of  lodged  missiles  are 
extremely  rare,  and  for  all  other  cases,  the  uncertahity  and  danger  of 
ex])loration  through  the  wound  are  done  awai\'  with  by  the  certain  and 
safe  action  of  the  Rontgeu  ray. 

NECESSITY  FOR  THE   LOCALIZATION   AND   REMOVAL   OF   LODGED  MISSILES. 

It  is  well  known  that  lodged  missiles  frecpientlv  become  encysted  in 
the  tissues  and  cause  no  further  trouble.  In  other  cases,  however,  they 
give  trouble  through  causing  suppuration,  or  by  pressure  upon  some  neigh- 
boring nerve  or  organ,  or  by  l)eing  so  situated  as  to  interfere  ^\•itll,  or  pro- 
duce })ain  during  muscular  action. 

Frecjuenfly,  also,  knowledge  of  the  i)resence  of  a  foreign  l)odv  causes 
mental  disquietude,  and  in  other  cases  it  is  important  to  know  the  exact 


LOCALIZATION  OF  LODCiED  MISSILES. 


47 


d-l--- 


lociition  of  file  missile  in  order  to  determine  wliether  tlie  symptoms  wliicli 
sometimes  follow  its  lodgment  are  due  to  the  lesions  incident  to  the  original 
traumatism  or  to  irritation  from  the  foreign  body,  or  wliether  or  not  the 
symptoms  may  not  he  due  to  something  entirely  unconnected  either  with 
the  original  traumatism  or  the  presence  of  the  lodged  missile.  In  such 
cases,  accurate  localization  of  the  bullet  is  of  the  greatest  imj)ortance  and 
value  from  a  standpoint  of  diagnosis  and  treatment. 

The  following  two  cases  are  illustrative  of  those  cases  in  which,  with- 
out accurate  localization  of  the  bullet,  it  is  impossible  to  determine  whether 
or  not  the  symptoms  are  due  to  the  effects  of  the  original  traumatism  or  to 
irritation  set  up  by  the  lodged  missile.  Case  1  is  illustrative,  also,  of  the 
aseptic  course  of  a  wound  made  by  a 
slow-moving  lead  bullet  when  left  tin- 
disturbed. 

Case  1.  Shrapnel  hall  lodged  in.  hack; 
traumatic  7ieu,TaKtheiiia;  localizatimi  hy  liiinf- 
(jcn  ray;  missile  not  removed. 

Richard  J.  Eskridgo,  major,  Toiitii 
United  Stiites  Infantry,  wounded  with  shrap- 
nel, July  2,  at  Santiago  and  transferred  to 
Massachusetts  General  Hospital,  where  fol- 
lowing historjr  was  noted: 

Ball  entered  back  while  he  was  sitting. 
Inuiiediate  shock  severe.  Intense  dyspncea. 
Complete  temporary  paralysis  of  the  left 
side.  After  being  taken  to  rear  was  able  to 
move  arm  and  wiggle  toes  slightlv.  I)ysp- 
noea  lasted  twenty-four  hours.  Severe  con- 
stant pain  in  lower  half  of  left  side  of  trunk 
and  left  leg.  Wound  healed  readily.  No 
wound  of  exit  found.  Paresis  of  leg  re- 
mained same  for  about  three  weeks,  then 
began  to  disappear  gradually  till  he  was  al)le  to  raise  his  leg  from  the  bed  about 
three  weeks  later.  Since  then,  improvement  less  rapid.  Pain  has  continued  with 
about  same  severity,  requiring  one-quarter  to  one-half  grain  of  morphia  at  night. 
More  severe  at  night;  more  severe  in  damp  weather. 

August  16.  Examination:  In  left  back,  2^  inches  from  median  line,  at  level  of 
ninth  rib,  a  round  scar  one-fourth  inch  in  diameter.  Marked  muscular  atrophy  of 
hip,  thigh,  and  leg  of  left  side.  'Phigh  and  leg  (left)  very  flabby.  Extreme  sensitive- 
ness of  thigh  and  leg,  most  marked  just  above  popliteal  space.  Knee  jeak  absent  on 
left  side.     Able  to  get  around  little  on  crutches  and  put  a  little  weight  on  left  leg. 


Fiii.  9. — Diagram  showing  location  of  wound 
of  entrance  (a)  and  position  of  bullet  (i) 
in  the  case  of  Maj.  Richard  Eski-idge, 
Tenth  United  States  Infantry. 


48  RONTGEN  KAY  IN  SPANISH- AMERICAN  WAR. 

November  ti.  X-ray  plates  taken;  bullet  found.  Three  plates  then  taken,  one 
dirertly  over  site  of  bullet,  one  on  either  side  at  angle  of  -to-.  These  located  bullet 
at  level  of  second  lumbar  intervertebral  disk.  H  inch  above  level  of  crests  of  ilium 
and  about  three-fourths  inch  to  1  inch  deep.  Removal  not  advised  l)y  neurologists, 
as  no  source  of  irritation. 

From  the  Massachusetts  General  Hospital  the  patient  was  transferred,  with  a 
diagnosis  of  traumatic  neuritis,  to  the  Army  and  Navy  General  Hospital.  Hot 
Springs.  Ark.,  and  thence  to  the  General  Hospital  at  Washington  Barracks. 

On  arrival  at  the  latter  hospital  the  same  symptoms  of  pain  and  local  hyper- 
asthesia  were  the  same  as  given  above.  The  motor  functions  of  the  left  leg  had 
considerably  improved.  Some  doul)t  existing  as  to  whether  the  symptoms  were  due 
to  the  original  traimiatism  or  to  pressure  from  the  bullet,  a  radiograph  was 
taken,  from  which  it  was  thought  that  the  l)ullet  (shrapnel)  lay  as  located  in  the 
Massachusetts  Hospital.  The  bullet  was  cut  for.  Imt  could  not  be  found.  The 
Mackenzie-Davidson  localizer  was  then  used  aud  with  it,  the  bullet  was  located 
considerably  deeper  and  in  the  subperitoneal  tissue  just  below  the  left  kidney.  As 
from  its  location,  it  could  by  no  possibility  be  causing  any  of  the  symptoms,  the 
neuritis  was  undoubtedly  traumatic,  a  result  of  the  original  lesion,  and  no  further 
attempt  was  made  to  remove  the  buUet. 

The  following  illiisti'ates  those  cases  iu  which  it  is  necessary  to  locate 
the  lodged  missile  in  order  to  determine  whether  symptoms  which  follow 
the  receipt  of  a  gunshot  wound  are  due  to  the  presence  of  the  bullet  or  to 
some  entu-ely  different  condition  : 

Case  2. — Fragment  of  missile  lodged  in  tin-  hack;  ncuralffia;  loca^'^mtion  of 
fragment  hy  Rbntgen  ray. 

Alfred  W.  Bjornstad.  captain.  Thirteenth  ]\Iinne.sota  Volunteers,  received  a 
slight  superficial  wound  of  the  left  shoulder  at  Manila.  P.  I..  August  13.  18t)S.  On 
turning  to  go  to  the  rear  to  have  the  wound  dressed,  he  was  struck  a  second  time  by 
what  he  thought  to  be  a  ricochet  bullet.  The  wound  of  entrance  was  3  inches  to  the 
left  of  the  spine  and  midway  between  the  ninth  and  tenth  ribs.  The  wound  was 
dressed  with  a  first-aid  di-essing  and  healed  without  trouble.  After  returning  to 
duty,  he  was  troubled  with  almost  constant  pain  in  his  right  side,  especially  when 
marching.  This  continued  until  he  was  returned  to  the  United  States  with  his 
reginuMit  to  be  mustered  out.  After  being  mustered  out,  he  was  appointed  captain 
in  the  Forty-second  United  States  Volunteer  Infantry,  and  as  the  pain  in  the  right 
.side  still  troubled  him  somewhat,  though  much  less  than  formerly,  he  applied  for 
treatment  before  being  returned  to  the  Philippine  Islands,  with  a  view  to  determine 
whether  or  not  the  pain  in  his  right  side  was  due  to  the  presence  of  a  lodged  l)ulli't. 
He  was  ordered  to  the  general  hospital  at  Washington  Barracks.  D.  C.  where  a 
Rontgen  ray  examination  was  made  and  a  small,  irregular  piece  of  metal,  probably  a 
fragment  of  a  bullet,  was  located  in  the  left  side  almost  directly  beneath  the  wound 
of  entrance.  Careful  examination  showed  no  other  missile  and  determined  the  fact 
that  there  was  no  lodged  bullet  on  the  right  side  producing  the  pain  from  which  the 
patient  was  suflering.  As  the  .small  piece  of  metal  on  the  left  side  was  producing 
no  trouble,  it  was  not  removed,  and  the  patient  left  the  hospital  shortly  afterwards. 


PLATE    XII. 


PLATE  XII. 

Case  3,  Section  3. — Jolui  Watson,  private,  Troop  F,  Teutli  United 
States  Cavalry. 

Radiooraph  of  left  leg,  viewed  from  the  back,  showing-  fragment  of 
missile  embedded  in  the  center  of  tlie  callus  formed  at  the  site  of  a  gunshot 
fi'acture  of  the  fibula. 


PLATE  XII. 


of  metal  J 


LOCALIZATION  METHODS.  49 

The  value  of  the  Roiitgen  vny  in  h)cating'  luissilc^s  or  sum]]  fragments 
of  missiles  wliich  have  infected  the  \Adnnd  and  cause  continued  su]i|)ura- 
tiou  is  shown  b}'  the  following  case: 

Case  3. — Fragment  of  mctaJ  lodycd  in,  fibula;  supjniratum.;  local izuf ion  hy 
Rbntgen  ray;  removal;  recovery. 

John  Watson,  private,  Troop  F,  Tenth  Cavalry,  was  wounded  July  1,  by  a 
missile,  supposed  to  be  a  Mauser,  which  entered  the  anterior  surface  upper  part  of 
middle  thii'd  right  leg,  fractured  the  fibula,  and  passed  out  at  the  internal  lateral 
surface.  The  patient  was  transferred  north  and  finally  to  the  general  hospital  at 
Washington  Barracks.  A  suppurating  sinus  persisted  at  the  site  of  the  original 
woiuid  of  entrance.  A  radiograph  was  taken  which  showed  a  small  fragment  of 
metal  embedded  in  the  callus  uniting  the  fractured  fibula,  (Plate  XII).  Operation 
disclosed  a  small  piece  of  lead  at  the  point  indicated.  This  was  removed,  the 
wound  promptly  healed,  and  the  patient  was  returned  to  duty. 

LOCALIZATION    METHODS. 

It  is  to  be  noted  tliat  Rontgen  rays  are  projected  in  right  lines  from 
the  anode  of  the  Crookes  tube.  As  a  consequence  of  this,  the  observed 
shadow  of  an  object,  the  object  itself,  and  tlie  anode  are  all  in  line.  This 
direct  projection  of  the  observed  image  is  both  an  advantage  and  a  disad- 
vantage in  locating  missiles  lodged  in  the  body.  It  is  a  disadvantage,  in 
that  erroneous  conclusions  may  be  formed  of  the  location  of  a  missile, 
unless  the  position  of  the  anode  and  the  position  of  the  shadow  of  the 
object  are  accurately  observed  and  noted.  For,  if  the  position  of  the  anode 
is  not  known,  the  foreign  body  may  lie  in  any  line  projected  from  the 
position  of  the  observed  shadow.  The  projection  of  the  shadow  of  an 
object  in  a  right  line  is  of  advantage  in  that,  knowing  the  jjosition  of  the 
anode  and  tlie  position  of  tlie  sliadow,  the  object  itself  must  be  at  some 
point  directly  between  the  two.  This  fact  of  the  direct  projection  of  the 
shadow  of  objects  has  given  rise  to  two  methods  of  localization  of  lodged 
missiles;   «,  by  direct  observation;   /;,  In'  multiple  observation. 

LOCALIZATION    BY    DIRECT    OBSERVATION. 

Direct  observation  has  to  be  employed  in  tliose  cases  in  wliich  lateral 
views  can  not  be  made  through  the  part  in  wliich  the  foreign  body  is  lodged. 
Thus,  in  examinations  made  for  foreign  bodies  in  the  chest,  abdomen,  pelvis, 
shoulder,  and  ujjper  part  of  the  thigh,  the  observation  has  to  be  made  from 
before  backward,  or  vice  versa.  As  no  lateral  views  can  be  obtained  by 
wliich  the  depth  at  which  the  foreign  body  lies  can  be  determined,  resort 


50 


KONTdEN  RAY  IN  SPANISH-AMEHR'AN  WAR. 


imist  he  had  to  otlier  means,  of  whidi  there  are  two;  lirst,  the  ii^e  of  some 
form  of  localizer,  disciissiou  of  which  will  be  taken  up  later:  and,  second, 
critical  ol)servation  of  the  image  of  the  foreign  body  and  its  relative  posi- 
tion. Bv  carefulh'  examining  the  outline  and  .size  of  the  image  of  the 
lodsred  missile  and  the  movement  of  its  iinaae  when  the  tube  is  shifted  from 
side  to  side,  the  depth  of  tlie  foreign  body  in  the  part  can  be  approximately 
ascertained. 

If  a  lodged  missile  is  verv  near  the  Huoroscopic  screen  or  the  photo- 
gi-aphic  ])late,  the  outline  of  its  shadow  will  be  quite  sharp.  If  farther 
away,  the  outline  of  its  shadow  will  be  blurred  and  indistinct  and  its 
size  increased;  the  blurring,  indistinctness  and  size,  increasing  with  the 
distance  of  the  lodged  missile  from  the  plane  u])on  which  its  shadow  is  cast. 

If  the  outline  of  a  lodged  missile  is  sharp  and 
distinct  in  the  radiograph,  it  indicates  that  the 
mi.ssile  is  near  the  surface  of  the  body  against 
which  the  photographic  plate  was  placed.  If, 
on  the  other  hand,  the  pictiire  of  the  lodged 
missile  appears  bluiTed  and  indistinct  in  the 
radiograph  or  on  the  screen,  it  is  an  evidence 
that  the  missile  is  at  a  considerable  dejjtli  in 
the  tissues.  The  increased  size  of  the  image 
of  a  deeply  placed  foreign  bod}"  is  due  to  the 
greater  dispersion  of  its  shadow  the  nearer 
the  body  lies  to  the  source  of  light  (tig.  10  h). 
Its  blurred  outline  is  due  to  the  fact  that  the 
Rilntgen  ravs  are  not  projected  from  a  single 
point  on  the  anode,  but  from  its  entire  surface. 
F.G  io.-Di^ram  showing  the  reia-     ^^    ^^^  ^.^^.^  ^^.^  ^^^^  projected  from  a  single 

tive  aze  of  umbra,  penumbra,  ana  -^  f     j  o 

shadow  in  foreign  iwdie.*  located     point,  they  cross  each  otlicr  at  the  edges  of 
superficially  („)  and  deeply  (6)  in     ^^  object,  forming  a  peuumbra,  and,  neces- 
sarily, the  penumljra  is  wider  the  greater  the 
ilistance  between  the  object  and  the  plane  upon  which  its  shadow  is  cast 
(fig.  10/>). 

In  making  these  observations,  photography  is  a  much  safer  guide  than 
visual  oliservtious  made  with  a  Huoroscope.  as  the  photographic  image  will 
show  dift'erences  of  outline  more  clearly  than  the  eye  can  determine  them. 
A  numljer  of  examples  of  the  relative  dimness  of  outline  and  variations 
in  size  of  the  image  of  lodged  missiles,  according  to  the  distance  of  the 
missiles  from  the  surface  of  the  body,  are  given  in  the  radiographs  accom- 
panying this  report. 


LOCALIZATION  METHODS.  51 

III  iiilditiou  to  tlic  lucrliDils  iilreaiU' g'iveii  tor  ;i])|)r()xiinatiiiL;' the  position 
of  lodg-ed  missiles,  advantage  can  be  taken  of  the  position  of  the  image  of  tlie 
foreign  bodies  relative  to  surface  markings  and  points  on  the  bones.  Thus  in 
Case  9,  Section  II,  the  position  of  the  observed  image  of  the  bullet  relative 
to  that  of  tlie  lesser  trochanter  and  the  fold  of  the  Ijuttock  was  of  the  greatest 
assistance  in  locating  the  bullet  at  the  time  of  operation,  while  the  dinniess 
of  outline  and  large  size  of  the  image  of  the  ball  indicated  that  it  was  deep 
in  the  part. 

A  still  further  means  of  approximating  the  depth  at  which  a  lodged 
missile  lies  in  a  part  is  to  note  by  the  Huoroscope,  the  distance  which  the 
image  of  the  object  moves  when  the  tube  is  shifted  laterall}-.  If  \\lien  the 
tube  is  moved,  the  image  moves  but  slightly,  the  missile  can  not  l)e  deep  in 
the  part;  while,  If  the  image  movement  is  considerable,  the  foreign  body  is 
probably  quite  dee])ly  placed. 

These  means  of  localizing  lodged  missiles  give  only  inferential  results, 
but  by  careful  observation  and  by  combining  all  possible  factors,  foreign 
bodies  can  be  localized,  in  a  majority  of  cases,  with  sufficient  exactness 
for  all  practical  purposes,  especially  if  they  are  not  deeplv  placed.  On 
account  of  its  size,  a  bullet  is  not  likely  to  be  missed  by  a  surgeon  when 
it  is  situated  superficially,  provided  the  operator  cuts  in  direct  line  from 
its  observed  shadow  toward  the  point  where  the  anode  of  the  Crookes 
tube  was  located.  But  in  pursuing  the  inethod  of  dhect  incision,  the  sur- 
geon must  be  quite  cei'tain  before  operating  that  the  body  for  which  he  is 
searching  is  situated  superficially,  or  he  may  have  to  cut  too  deeply  or 
through  important  stractures  to  find  it. 

Wliei-e  foreign  bodies  are  deeply  placed  or  in  the  neighborhood  of 
important  structures  or  organs,  it  is  necessarv  that  they  be  accuratelv 
located  before  operative  interference  is  adopted,  and  in  such  cases  one  of 
the  methods  of  localization  by  multiple  observation  must  be  resorted  to. 

LOCALIZATION   BY   MULTIPLE  OBSERVATION. 

Localization  by  multiple  observation  covers  all  the  methods  of  localiza- 
tion in  which  the  location  of  the  foreign  body  is  determined  b}'  observa- 
tions, so  made,  that  the  right  lines  of  light  from  the  anode  cross  each  other. 
As  the  anode,  the  observed  body  and  its  shadow  nre  alwavs  in  line;  when 
two  observations  are  made  with  the  anode  in  different  positions  at  each 
observation,  it  must  follow,  that  the  observed  bod^'  must  lie  at  a  point  where 
tlie  lines  drawn  fi'om  the  anode  to  the  shadow  of  tlie  bo(U'  cross  each  otlier. 


52  H()NTG1-:N  ray  in  SPA^'1SH-AMEKICA^'  WAR. 

As  ;i  (•(•us('(|ii('iicc'  ot"  this,  it'  two  obst'vvatious  nre  nuule  with  the  .mode  in 
(htVcreiit  positions,  iuid  these  positions  and  the  i)oints  ou  the  surface  of  the 
l)(>(h-  whc'iv  tlie  iinaiivs  of  the  missile  are  projeeted  are  recorded,  then  tlie 
inissiU^  can  be  accurately  located  at  the  point  where  lines  cross  each  other 
which  are  drawn  from  the  positions  occupied  by  the  anode  to  the  points  on 
the  surface  of  the  body  where  the  shadows  of  the  missile  were  cast. 

A  number  of  means  have  been  de\'ised  for  determining-  the  position  of 
tlie  anode  and  the  shadow  of  foreign  bodies  relative  to  the  surface  of 
that  part  of  the  body  in  which  the  foreign  body  is  located.  The  most 
common  method  is  to  make  an  observation  and  mark  upon  the  skin  the 
point  whei"e  tlie  shadow  of  the  foreign  body  is  thrown,  then  to  move  the 
anode  to  a  ])osition  where  it  will  approximately  project  the  Rontgen  rays  at 
right  angles  to  the  first  observation,  and,  after  marking  on  the  skin  the  point 
where  the  second  shadow  of  the  foreign  body  is  cast,  the  operator  can,  by 
angulation,  approximately  determine  the  point  where  the  foreign  body  lies. 
This  method,  like  the  method  by  single  observation,  is  generally  sufficient 
for  cases  where  the  missile  lies  supei-ficially  or  in  close  relation  to  some 
bony  point.  Examples  of  this  method  of  determining  the  position  of  lodged 
mis.siles  by  right-angled  observation  are  given  in  Plate  XIII,  and  in 
Plate  XXXIII. 

But  where  the  bullet  is  lodged  deeply,  this  method,  like  the  method  by 
direct  observation,  while  sufficient  for  some  cases,  can  not  be  depenrled  upon 
for  accuracy,  and  instruments  have  been  devised  for  definitely  fixing  the 
position  of  all  the  jjoints  necessary  to  accurate  localization;  namely,  the 
positions  of  the  anode,  the  places  on  the  surface  of  the  body  where 
the  projected  shadows  of  the  foreign  body  are  thrown,  and  the  position  of 
these  points  relative  to  each  other. 

These  instruments  are  divided  into  two  classes;  those  in  which  pho- 
tograph}^ is  used,  and  those  in  which  visual  eflFects  are  relied  upon. 

Instruments  of  each  class  have  been  used  and  lune  l)een  found  of  great 
value  in  difficult  cases  arising  from  the  late  war. 

PHOTOGRAPHIC    APPARATUS    FOR    LOCALIZATION. 

]\Iackciizie-Davidsou  devised  and,  in  181)8,  descrilx'd  a  method  of 
localization,  since  known  as  the  crossed-thread  system.'  This  method,  either 
with  Mackenzie-Davidson's  original  a})j)aratus  or  one  of  its  modifications,  is 
probal)ly  tlic  most  ace m'ate  and  reliable  means  now  used  for  the  localization 

1  Mafkoiizie  Davidson.    Rijntgcn  ray  and  localization.  British  Medical  .Journal,  January  1.  1898. 


PLATE   XIII. 


PLATE   XIII. 

Case  4,  Section  II. — John  N.  Taylor,  private,  Conipaii}-  I>,  Twulfth 
United  States  Infantry. 

Radiographs  of  the  left  foot,  viewed  from  the  inner,  and  from  the 
plantar  surface,  showing-  a  sllti-htlv  deformed  bullet  embedded  in  the  sole 
of  the  foot,  beneath  the  cuboid  bone  and  in  a  line  with  the  second  metatarsal 
bone.     The  two  views  accurately  locate  the  missile. 


PLATE  XIII. 


I 


MACKENZIE-DAVIDSON  LOCALIZER. 


53 


of  foreign  bodies  with  the  Routgeu  ray.  The  Mackenzie- Davidson  appa- 
ratus consi.sts  of  two  part.s,  tlie  exposer  (%.  II),  and  tlie  h)calizer  (%.  12). 
By  means  of  the  exposer,  tliat  part  of  the  body  in  wliich  the  foreign 
body  is  lodged  is  fixed  in  a  definite  position  relative  to  a  photograpliic 
plate.     Two  exposures  are  then  made  upon  the  same  plate  with  the  anode 


Fui.  11. — Mackenzie-Davidson  expuser.  Tlic  ph<it(if.'i:i|)hic  I'hitc  is  |il:icccl  liciicatli  Ihr  crossed 
wires  on  the  board.  The  wires  are  inked  and  leavi'  marks  on  the  .skin  of  the  ]iart  and  tlie  image  of 
the  wires  apjieans  on  the  neijative.  Tliis  j^ivi's  Hnes  for  loi'alization.  Tlie  tube  is  suspended  vertieally 
above  the  transverse  wire  and  eqnidistant  at  each  exjiosure  from  a  iioint  vertically  aliove  where  the 
wires  cross. 

in  dift'ert'Ut  position  for  earh  exposure,  the  position  of  the  anode  being  by 
means  of  the  apparatus  accurately  fixed  and  determined  for  each  exposure. 
The  j)late  being  then  develo])ed,  two  images  of  the  shadow  of  the  foreign 
body  will  appear  in  the  negative. 


54 


RONTGEN  RAY  IN  SPANISH-AMERICAN  ^\AR. 


By  placing  the  uegativL-  iu  the  locahzer  (fig.  12),  and  stretchiug  tlu-eads 
from  corresponding  points  of  the  two  images  on  the  negative  to  the  posi- 
tions which,  relative  to  these  images,  were  occupied  by  the  anode  at  each 


Fui.  12. — Mackenzie-David^^ou  localizer.  The  negative  is  placed  on  the  glass  plate  in  tlie  same 
position  relative  to  the  two  points  on  the  crossbar  that  it  occupied  relative  to  the  anode  when  the 
exposure  was  made.  Weightipd  threads  are  then  stretcheil  from  corresponding  [Mjint.s  on  the  image  to 
the  ixiints  on  the  crossbar,  and  their  jioint  of  cros.'^ing  indicates  tlie  position  which  the  Imlgetl  missile 
occupied  relative  to  the  i)late  wlien  the  exi)ostue  wa.-^  made. 

exposure,  the  threads  will  cross  at  a  distance  and  jjosition  from  the  negative 
which  the  foreign  body  occupied  at  the  time  that  the  negative  was  made. 


() 


CROSSB]D-THREAD  LOCALIZATION.  55 

By  measuring  the  location  of  the  point  wliere  the  threads  cross,  the  position 
f  tlie  foreiu-ii  body  in  tlie  tissues  is  then  determined  liy  marking's  made  on 
the  skin  at  the  same  time  that  tlie  negative  was  taken.  In  this  wav,  foreign 
bodies  can  be  located  with  mathematical  exactness. 

The  method  in  detail  is  ms  follows :  Radiographs  are  taken  from  two 
different  points  of  view.  In  order  to  carry  out  the  adjustment  and  move- 
ment of  the  Crookes  tube,  a  horizontal  bar  is  used  with  a  scale  upon  the 
front  of  it,  graduated  in  millimeters,  with  0°  at  the  middle  point  of  the  bar 
(fig.  11).  This  bar  slides  up  and  down  ujjon  the  two  rods  which  rest  upon 
the  floor,  each  with  a  base  similar  to  those  in  stanilard  lamps.  There  is  a 
small  holder  for  the  Crookes  tube,  which  slides  horizontally  along  the  bar, 
and  there  are  two  sliding-  checks,  which  can  be  fixed  by  means  of  a  small 
screw  at  any  desired  points  on  the  scale,  thus  enabling  the  tube  to  be 
({uickly  and  accurately  removed  from  jxisition  on  one  side  of  0°  to  a  corre- 
sponding point  on  the  other  side. 

In  case  it  is  desired  to  adjust  the  (Jrookes  tube  to  any  particular  height, 
there  is  a  small  bar  which  slides  vertically  up  and  down  and  carries  the 
tube  with  it  and  acts  as  a  fine  adjustment;  a  small  thumbscrew  clamjjs  it. 
There  is  a  small  spirit  level  fixed  on  the  top  of  the  carrier  of  the  Crookes 
tube. 

The  method  of  taking-  tlie  radiograph  is  as  follows:  '^riie  first  step  in  the 
process  is  to  measure,  as  accurately  as  jiossible,  tlie  height  of  the  point  of  origin 
of  the  Rontgeu  rays  above  the  photographic  plate  or  film,  and  generally  for 
all  practical  purposes,  the  middle  (jf  the  anode  plate  may  be  taken  as  the 
radiant  point.  The  sliding  holder  with  the  tube  is  placed  with  one  of  its 
edges  on  O"  of  the  scale  on  the  horizontal  bar.  The  check  clips  are  adjusted 
on  either  side  of  the  O"  to  the  desired  degree  of  displacement  and  fixed  there, 
so  as  to  allow  of  equal  displacements  of  the  tube  to  either  side  of  0°.  The 
amount  of  displacement  of  the  tube  does  not  seem  to  affect  the  accuracy  of 
the  results;  a  displacement  of  7  cm.  to  each  side  of  zero  working  well  in 
practice,  though  other  distance  may  be  required  in  some  cases 

On  the  table  below  the  tube  there  is  a  board  with  two  fine  wires 
stretched  across  it  at  right  angles,  and  dividing  it  into  four  equal  parts  (see 
fig.  11).  It  should  be  considerably  larger  than  the  largest  photographic 
jilate  or  film  which  is  to  be  iised,  so  that  the  plate  or  film  covered  with 
black  paper  hi  the  usual  way  can  be  slipped  beneath  the  cross  wires.  Or, 
instead  of  the  board,  two  wires  can  be  tied  directly  across  the  covered 
photographic  plate.  The  adjustments  now  necessary  are  as  follows:  Put 
the  tube  holder  at  O",  and  then  with  a  small  plumb  line  drop  a  perpendicular 
miH 6 


56  RONTGEN  EAY  in  SPANISH-AMERICAN  WAR. 

fi-om  the  middle  of  the  platinum  auode.  The  board  is  then  placed  so  that 
the  point  wliere  the  wires  upon  it  cross  is  just  under  the  plumb-line  needle; 
in  tact,  vei-ticallv  below  the  center  of  the  auode.  Further,  the  board  must 
be  so  placed  that  one  of  the  wires  is  parallel  to  the  plane  in  which  the  tube 
is  to  be  placed;  that  is,  it  must  be  made  to  lie  parallel  to  the  horizontal  bar. 
This  can  be  done  by  mere  inspection  by  looking-  along-  the  edge  of  the 
horizontal  bar  and  seeing  that  the  wire  is  parallel  to  it.  Once  these  adjust- 
ments are  made,  the  board  can  be  fixed  to  the  table  and  the  instrument  is 
readv  for  use  at  au\  time  without  further  adjustments  being  necessary. 

The  distance  of  the  center  of  the  anode  A-eitically  from  the  plate  is 
carefully  measured  and  recoi'ded.  The  tube  holder  is  now  displaced  to  the 
previously  fixed  check  clip  on  one  side.  The  cross  wires  are  lightly  brushed 
over  with  some  suitable  dye  (the  ink  used  for  rubber  stamps  is  ■  good). 
The  plate,  covered  as  usual,  is  then  slipped  beneatli  the  cross  wires.  The 
patient  now  places  the  part  to  be  photographed  on  the  plate  and  a  "small 
object,  opaque  to  Rontgen  rays  (a  small  coin  answers  well),  is  placed  on 
one  of  the  corners  of  the  plate,  so  as  to  mark  a  quadrant.  The  current  is 
turned  on  and  one  exposure  made.  It  is  then  stopped  for  an  instant  till 
the  tube  is  pu.shed  over  to  the  other  side  of  0",  to  where  the  other  check 
clip  had  been  previously  fixed,  and  then  another  similar  exposure  is  given 
on  the  same  plate  and  without  the  patient  mo^•ing•.  When  the  })atient 
raises  the  part  from  the  plate  he  should  can-y  the  mark  of  the  cross  wires  in 
ink  and  it  is  important  to  make  a  small  mark  on  the  quadrant  of  his  skin, 
which  con-esponds  to  the  quadi-ant  on  the  plate  upon  which  the  opaque 
object  was  placed.  This  is  clearly  necessary  to  keep  the  parts  and  the 
negative  in  register. 

The  negative  is  at  once  developed  and  fixed  in  the  usual  wa}',  when 
two  shadows  of  the  foreign  body  will  appear.  If,  for  example,  the  foreign 
body  is  a  bullet,  there  will  be  two  bullet  shadows  in  the  negative. 

From  the  above  data  and  with  this  negative  one  can,  bv  means  of 
mathematical  forumlje  or  geometrical  tb'awing  to  a  scale,  arrive  at  a  correct 
knowledge  of  the  position  of  the  bullet.  But  the  refjuisite  knowledge  is 
not  always  at  hand;  and  the  second  part  of  the  apparatus  is  now  bi-ought 
into  use.     Fig.  12  shows  the  apparatus  called  the  "localizer." 

It  resembles  a  photographer's  retouching  desk.  Upon  an  iron  stand  a 
piece  of  plate  glass  is  placed  horizontally  and  beneath  it,  a  mirror  which  can 
be  adjusted  so  as  to  reflect  the  light  from  a  window  or  lamp  up  from  below. 
There  is  a  horizontal  bar  which  slides  U])  and  down  upon  two  vertical  rods. 
On  this  bar.  there  is  a  millimeter  scale  with  a  small  n()tch  at  each  millimeter 


CROSSED-THREAD  LOCALIZATION.  57 

mark.  The  0"  is  at  the  middle  point  of  thi.s  l)ar.  On  tlie  o-]ass  plate  there 
are  two  lines  cut  with  a  diamond  at  right  angles  to  each  other  (to  corre- 
spond to  the  cross  wires  on  the  vulcanite  plate),  and  this  glass  plate,  which 
is  movable  and  can  be  clamped,  is  so  placed  tliat  the  point  where  the  lines 
cross  is  vertically  beneath  the  O"  on  the  scale  above,  and  the  line  on  the 
glass  running  right  and  left  (when  facing  the  scale)  is  placed  parallel  to  the 
edge  of  the  scale.  In  other  words,  they  are  in  the  same  vertical  plane. 
The  scale  is  now  raised  or  lowered  so  as  to  make  the  O"  on  it  precisely  at 
the  same  height  vertically  above  the  negative  as  the  anode  of  the  Crookes 
tube  was  from  the  photographic  plate  or  film  when  the  negative  was  being- 
produced. 

The  negative  being  washed  after  fixing,  can  be  at  once  placed  upon  the 
horizontal  stage  and  easily  adjusted,  so  that  the  white  lines  produced  by 
the  cross  wires,  are  made  to  coincide  with  the  cross  line  on  the  g-lass  plate, 
care  being  taken  that  the  marked  (juadrant  is  in  the  same  relative  position 
as  it  occupied  when  the  photograph  was  being  taken.  As  a  routine  pi'actice, 
it  is  best  to  mark  the  right  upper  quadrant,  as  the  operator  stands  facing 
the  scale  on  the  l)ar. 

It  is  important  to  remember  that  the  negative  should  be  placed  face  up 
on  the  stage,  for  if  placed  on  the  stage  with  the  gelatin  face  downward  the 
relations  of  the  parts  are  reversed. 

The  negative  being  thus  arranged,  it  will  be  seen  that  it  is  really 
placed  under  exactly  the  same  conditions  as  it  occupied  when  it  was  being 
taken.  Under  these  circumstances,  all  that  is  now  recpiired  is  to  trace  the 
path  of  the  rays  which  produced  the  negative.'  This  is  done  in  a  very 
simple  way.  The  distance  on  each  side  of  the  middle  p(jint  (( )°  on  the 
scale)  to  which  the  anode  was  displaced  is  known.  Suppose  it  was  7  cm., 
a  tine  white  silk  thread  is  placed  in  the  notch  7  cm.  to  one  side  of  0°  and 
another  silk  thread  (red)  is  placed  in  the  notch  7  cm.  to  the  other  side  of 
0°.  Small  weights  are  attached  to  one  of  the  ends  of  each  thread  to  keep 
them  taut,  while  the  other  is  threaded  into  a  fine- needle,  which  is  weighted 
by  being  fixed  into  small  lead  weights,  in  shape  resembling  a  mouse 
(Figs.  12  and  13). 

Now,  these  threads  can  be  used  to  show  the  path  of  the  rays  which 
produced  the  negative.  Suppose  we  are  dealing  with  a  bullet  in  some  part 
of  the  body.  On  looking  down  on  the  negative  we  find  two  bullets,  and 
it  is  not  difficult  to  see,  that  as  the  Crookes  tube  was  displaced  horizontally 
in  a  line  running  right  and  left,  that  the  shadow  of  the  l>ullet  to  the  left 
was  produced  by  the  tube  when  displaced  to  the  right,    and  vice  versa. 


58 


rONTGEN  ray  in  SPANISH-AMERICAN  WAR. 


Thus,  if  we  place  one  of  the  threads  on  the  point  of  the  bullet  in  one  shadow, 
it  will  indicate  the  path  of  the  ray  that  produced  the  shadow  of  tlie  bullet 
point  (P.  fig.  13.)      Now,  if  the  other  thread  is  placed  on  the  ciiiTespond- 

ing  point,  of  the  other  bullet  shadow 
(P\  fig.  13),  then  it  must  follow  that 
the  position  actually  occupied  by  the 
point  of  the  bullet  in  question  is  pre- 
ciseH'  where  the  two  thrends  cross  at 
c  in  fig.  13. 

If  the  perpendicular  distance  of 
a  point  can  be  measured  from  three 
planes  which  are  at  right  angles  to 
each  other —  in  short,  if  the  x,  ?/,  and  z 
t-an  be  ascertained — then  all  will  be 
known  about  the  position  of  the  point 
in  question. 

This  we  can  do  at  once  with  the 
point  c  in  fig.  13.  First,  the  vertical 
distance  from  the  negative  to  where 
the  threads  cross  each  other  is  measured.  This  is  the  distance  of  the  point 
of  the  bullet  beneath  the  skin  (of  the  patient),  which  rested  <.n  the  photo- 


FiG.  13.— Diagram  showing  metlioil  of  using  tlif 
localizer  (Mackenzie  Davidson). 


-V 


4.  <l 


/tarKfd 
QuCLcL  rant 


3  (.  m. 


3vli 


tH  ^Ji^ 


Fig.  14. — Diaprani  showing  method  of  localization  (Mackenzie-Davidson). 

gi'aphic  plate.    This  can  be  measured  with  an  ordinary  pair  of  compasses. 

The  vertical  distances  are  next  measured  from  the  two  vertical  planes 
represented  by  the  shadows  of  the  cross  wires  to   the  point  where    the 


CROSSED-THKEAD  LOCALIZATION.  59 

threads  cross.  An  uijright  squnre  is  placed  with  its  edge  coincident  with 
the  shadow  of  one  of  the  wires,  and  tlie  ])erpendicular  distance  is  meas- 
ured witli  compasses  from  it  to  the  pt>int  wliere  the  thi-eads  intersect.  In 
this  way  ./,  y/,  and  .=-  of  the  point  of  tlie  bullet  is  ascertained  and  the  result 
noted  down,  as  shown  in  fig.  14.  Tiie  arrows  in  fig.  14  indicate  the  direction 
of  the  disi)lacements  of  the  Crookes  tube.  We  then  jjroceed  in  a  similar 
manner  to  ascertain  the  position  of  tlie  butt  of  the  bullet  c,  in  fig.  13.  And 
the  distance  between  .•  and  r'  in  fig.  13  gives  the  direction  and  actual  length 
of  the  bullet. 

From  the  measurements  jotted  down,  as  shown  in  fig.  14,  a  line  can 
be  marked  on  the  patient's  skin  in  the  same  plane  as  the  bullet,  and  the 
surgeon  can  be  given  the  exact  depth  at  which  each  of  its  extremities  can 
be  reached  by  a  vei'tical  puncture. 

Several  pairs  of  threads  might  be  used,  and  in  this  way  the  shape  of 
the  fin-eign  body  might  be  outlined ;  but  it  is  more  convenient  to  use  one 
pair.  The  point  where  they  intersect  can  be  fixed  by  the  point  of  a  surface 
gauge;  and,  when  the  threads  are  moved  to  another  position,  the  diiference 
between  their  new  point  of  intersection  and  their  former,  where  the  point 
of  the  surface  gauge  stands,  can  be  measiu-ed  at  once.  In  fig.  13,  the  dark 
fines  indicate  the  position  of  the  threads,  the  dotted  lines  show  the  position 
they  occupy  when  they  are  each  directed  to  the  butt  of  the  bullet,  and  the 
distance  from  c  to  c'  is  the  actual  length  of  the  bullet.  It  also  indicates  the 
direction  in  which  the  bullet  lies. 

The  final  result  of  the  process  is,  that  we  can  draw  an  outline  of  the 
foreign  body  on  the  patient's  skin  and  give  the  depth  below  the  skin  of 
any  of  its  parts,  and  this  enables  us  to  give  the  direction  and  depth  at 
which  it  can  be  reached  from  any  point  the  surgeon  may  select. 

The  original  Mackenzie-Davidson  localizer  has  been  modified  on  the 
lines  of  portability  and  simplicity,  but  the  principle  remains  the  same.  In 
the  Harrison  portable  localizing  apparatus,  the  essential  features  are 
retained  and  the  apparatus  is  made  very  portable  and  consequently  well 
adapted  to  military  surgical  use. 

This  apparatus  (fig.  15),  consists  of  a  baseboard  which  supports  a  slid- 
ing tube  holder.  The  tube  is  fixed  at  a  certain  height  above  the  surface 
of  the  board,  and  radiographs  are  taken  with  the  tube  at  each  extremity  of 
the  slide.  The  negative  is  then  developed  and  placed  on  the  baseboard. 
Two  pillars,  which  plug  into  the  board,  are  so  arranged  that  a  small  notch 
at  the  top  exactl}'  coincides  with  the  two  points  from  which  the  radiographs 
were  taken  without  an}    measuring  or  calculations,  and  silk  tlu-eads  con- 


60 


RONTGEN  ray  in  SPANISH-AMERICAN  WAR. 


uecti'd  to  weighted  pointers  are  taken  from  these  piUars  to  the  image  on 
the  negative,  as  in  MacKenzie-Davidson's  apparatus. 


Pig.  15. — llarrisou  jjurtuble  localiziug  api>aratus. 

The  tube  holder,  piUars,  etc.,  are  all  removable,  and  can  be  packed  flat 
witli  the  board. 

APPARATUS   FOR   LOCALIZATION   BY  VISUAL  OBSERVATION. 

But  one  form  of  a])paratus  of  this  type  has  been  used  l)y  the  Medical 
Department  of  the  Uniied  States  Army.  It  is  known  as  the  Dennis 
fluorometer  (fig.  16). 

This  is  an  instrument  bv  means  of  which  the  position  of  the  anode, 


Flu.  lli. — The  Deuuis  fluorometer. 


tlu^  foreign  body,  and  its  shadow  as  projected  upon  the  surface  of  the  body 
mav   l)e   noted   b\-  \isual    oljservation    tlirougli  the    tluoroscope.     With  it. 


DENNIS  FLUOROMETER.  61 

lociilization  i,s  made  \>y  (leterminiug-  the   position  of  tlie  foreign  body  by 
two  observations  made  at  rig-ht  aiioles  to  each  other. 

The  instrnment  consists,  essentially,  in  a  set  of  carefully  designed 
metallic  angle  pieces  which  conform  generally  to  the  shape  of  the  body  or 
lind),  and  which,  in  their  use  in  connection  with  the  Rontgen  ray-s,  are 
susceptible  of  being  squared  with  a  simple  and  conveniently  adjustable 
table.  The  patient  being  laid  on  the  table  and  a  fluorometer  appliance 
adjusted,  the  Huorometer  is  brought  into  the  jjarallelism  of  the  rays — that  is, 
when  the  proper  position  of  the  cross  section  is  obtained,  the  two  arms  of 
the  fluorometer  will  present  the  characteristic  single  shadow  on  the  field  of 
the  fluoroscope. 

Attachable  to  the  arms  of  the  fluorometer  are  two  pins  or  sights.  By 
means  of  these  sights,  the  foreign  object  having  been  brought  in  line  with 
them  and  the  proper  adjustment  having  been  made,  a  correct  line  is  pro- 
duced, with  the  sights  and  foreign  t)bject  coincident. 

By  means  of  a  metallic  grating  of  inch  mesh,  which  is  placed  adjacent 
to  one  side  of  the  body  and  consequently  one  side  of  the  fluorometer,  exact 
measurements  can  be  made  with  the  eye  from  the  base  line  of  the  fluoro- 
meter and  from  points  on  the  circumference  of  the  body  to  the  foreign 
object. 

Then,  without  moving  the  body  or  the  fluorometer,  the  Crookes  tube 
is  placed  directly  over  the  subject  for  the  purpose  of  obtaining  the  vertical 
line.  By  means  of  an  adjustable  crosspiece,  which  is  placed  over  the  arms 
of  the  fluorometer,  exactly  the  same  results  in  a  vertical  way  are  obtained 
by  viewing  the  subject  from  beneath,  the  same  condition  of  parallelism 
having  been  produced,  another  set  of  pins  having  been  placed  in  position. 

It  will  be  seen  at  once  that  while  the  first  operation  locates  the  foreign 
object  on  an  exact  cross  section,  the  second  observation  shows  the  exact 
position  occupied  by  the  foreign  object  in  that  cross  section. 

All  the  elements  of  distortion  having  been  eliminated,  the  foreign 
body  will  necessarily  be  at  the  intersection  of  the  two  lines  of  the  right 
angle. 

In  practice,  the  surgeon  indicates  the  first  cross  section  obtained  by  a 
line  of  India  ink  or  iodine  on  the  body,  and  is  thus  enabled  to  establish 
the  position  of  the  object  by  measurements  from  points  on  the  exterior  of 
the  subject,  with  as  much  exactness  as  if  the  body  or  limb  were  actually 
severed  at  the  first  cross  section  and  presented  to  view. 

The  fluorometer  is  a  useful  ai)paratus  in  many  cases.  But  on  account 
of  the  difficulty  and  frequent  impossibility  of  using  the  fluoroscope  where 


62  RONTGEN  hay  in  SPANISH-AMERICAN  WAR. 

iniMsik's  are  lodged  in  the  thicker  parts  of  tlie  body,  especially  in  re^'ions 
where  dense  shadows  are  cast  by  the  contained  organs  of  the  abdominal 
cavity,  this  apparatus  has  only  limited  use  and  can  not  compare  with  the 
Mackenzie-Davidson  or  cross-thread  apparatus,  which  are  applicable  to  all 
cases. 

It  is,  however,  onlv  in  exceptional  cases,  and  those  of  considerable 
rarity,  that  recourse  will  have  to  be  made  to  either  form  of  localization 
apparatus.  In  the  great  majority  of  cases,  visual  obsei'vation  or  radiographs 
will  oive  all  necessary  information  to  the  suro-eon  relative  to  the  location  of 
lodged  missiles.  For  this  reason,  in  military  surgery,  it  would  not  seem 
necessary  to  supplement  every  RiJntgen  apparatus  with  one  of  these  appa- 
ratus. They  should,  however,  be  available  for  use  at  a  few  general  hospitals 
where  cases  of  marked  difficulty  can  be  sent  for  treatment 


IV. 

GUNSHOT  FRACTURES  OF  THE   DIAPHYSES  OF  LONG  BONES. 

In  gunsliot  fractures  of  the  shaft  of  long-  b.^ies,  tlie  extent  of  the 
fracture,  its  form,  and  the  amount  of  communition  vary  considerably 
according-  U\  the  cdnditions  which  obtain  at  the  time  of  the  receipt  of  the 
traumatism.  The  conditions  which  influence  the  bone  lesion  are  the  part 
of  the  bone  struck,  the  structure  of  the  bone  at  the  place  of  impact,  the 
velocity  and  form  of  the  missile,  and  the  angle  of  incidence.  As  all  these 
factors  can  hardly  be  identical  in  any  two  cases,  bone  lesions  are  bound 
to  vary  within  certain  limits. 

Of  great  importance  in  these  factors  is  the  part  of  the  bone  struck. 
The  physical  qualities  of  the  cancellous  tissue  of  the  epiphyses  are  so  different 
from  those  of  the  compact  tissue  of  the  shaft  of  the  long  bones  that,  under 
conditions  of  gunshot  impact,  different  traumatic  results  occur  according  to 
whether  one  or  the  other  of  these  parts  is  struck. 

The  results  of  Rontgen-ray  examinations  made  during  the  late  war 
lead  to  the  conclusion  that,  minor  differences  apart,  gunshot  lesions  of  the 
shafts  of  long  bones  by  small-caliber  bullets  may  be  divided  into  three 
main  classes : 

Class  1,  fractures  by  bullets  having  sufficient  velocity  to  produce 
perforating  wounds. 

Class  2,  fractures  by  uudeformed  bullets  having  sufficient  velocity  to 
penetrate  only. 

Class  3,  fractures  by  penetrating,  deformed  bullets. 

A  possible  fourth  class,  namely,  fractures  produced  by  deformed 
bullets  traveling  at  velocity  sufficient  to  produce  perforating  wounds,  is  not 
recorded  and  would  be  extremely  difficult  to  determine.  Such  bullets  pass 
through  the  part  wounded,  and  the  only  evidence  that  the  fracture  had  been 
made  by  a  deformed  missile  would  be  an  atypical  appearance  of  the 
wounds  of  entrance  and  exit,  appearances  wliicli  are  not  alwajs  present,  and 
which  if  present  would  lead  to  inferential  conclusions  only. 

CLASS   I.— FRACTURES   BY   PERFORATING   BULLETS. 

Under  this  class  come  all  fractures  produced  by  bullets  traveling  with 
sufficient  velocity  to  pass  out  of  the  wounded  part  after  having  fractured 
the  bone.     So  far  as  observed,  fractures  by  perforating  bullets  have  one 

63 


(54  k(")NT{jp:n  hay  in  spanisii-amekican  wak. 

comiium  charactcristif:    tlii-y  are  all  more  or  less  (•(nnininuted.     The  amount 
uf  comminution  apparently  depends  mainly  «>n  two  factors: 

First,  the  velocity   of  the  missile;   second,  the   angle   of  incidence  of 

impact. 

Where  the  velocity  of  the  bullet  is  extreme,  as  at  sliorl  range,  the 
amount  of  connninution  is  considerable,  and  is  greater  tlian  at  long-  rang-e, 
whatevei-  the  angle  at  which  the  bullet  strikes  the  bone. 

With  lowered  velocity,  comminution  is  great  only  when  the  bullet 
strikes  the  shaft  of  the  Ixme  in  the  median  line. 

Under  the  condition  of  extreme  velocity,  the  so-called  "explosive" 
effects  are  jn-oduced. 

Under  the  condition  of  median  imiiact,  connninution  of  bone  is  con- 
siderable, but  not  so  great  as  where  the  effect  is  explosive,  mdess  the  factors 
of  high  velocity  and  perpendicular  impact  combine.  For  these  reasons, 
fractures  of  the  hrst  class,  namely,  those  made  by  perforating-  bullets,  may 
be  divided  into  three  subclasses,  in  the  order  of  the  amount  of  lione  com- 
minution jjroduced: 

Subclass  1,  fractures  by  perforating  l)ullets  at  short  range. 

Subclass  2,  fractures  by  |)erforating  bullets  striking  the  bone  in  the 
median  line. 

Subclass  3,  fractures  V)y  l)ullets  striking  the  b()ne  tangentially. 

SUBCLASS  1.— FRACTURES  BY  PERFORATIXU  BULLETS  AT  SHORT  RANGE. 

In  tills  class  there  is  the  maximum  amount  of  bone  splintering  (explo- 
sive effect),  and  the  lateral  destructive  action  of  the  bullet  is  so  great  in 
some  cases  that  fractures  are  produced  even  when  the  bullet  barely  grazes 
the  V)one  (Case  2). 

^luch  has  been  written  of  the  explosive  effect  produced  by  the  modern 
bullet,  and  man\-  theories  have  been  advanced  to  explain  it.  In  the  opinion 
of  the  writer,  the  theorA'  which  l)esf  explains  this  effect  of  the  bullet  is  that 
the  destrui'tive  effect  is  the  result  of  the  latei'al  transmission  of  energy 
imparted  to  the  tissues  h\  a  rapidly  moving-  missile.^  If  energy  were 
ti-ansmittetl  only  in  a  line  directly  in  front  of  a  Ijullet,  the  IniUet  would 
make  clean-cut  ])erforations  in  all  organs  or  tissues  through  which  it  passed, 
and  inunediately  fatal  results  would  arise  only  from  direct  womids  of  blood 
vessels,  perforations  of  the  heart,  or  impingement  of  the  bullet  upon  some 
vital  part  of  the  ceuti'al  nervous  system. 

'Stephenson:  Wounds  in  War,  p.  7L     New  York,  1898. 

FonviKxl:  Wiirien  A  Lioiilil's  International  Text  Book  of  Siirfjciv,  Vol.  IL     I'liiludiliiliia.  liHK). 


GUNSHOT  OF  THE  DIAPHY8ES. 


65 


TIk'  lateral  tniusmis.sioii  of  tlie  energy  of  the  bullet  to  an  extent  suffi- 
cient to  cause  extensive  solutions  of  continuity  occurs  in  marked  degree 
only'in  certain  organs  and  tissues,  and  in  these  only  when  the  velocity  of 
the  missile  is  great.  As  this  destructive  effect  occurs  only  in  certain  organs 
and  tissues,  it  must  follow  that  it  is  because  these  organs  and  tissues  best 
transmit  the  energy  imparted  by  the  Ijullet;  and,  as  the  strui-tures  which 
transmit  this  energy  with  traumatic-producing  violence  are  either  compact 
bone,  or  organs  containing  fluid,  or  those  practically  saturated  with  fluid, 
it  seems  most  probable  that  this  energy  is  transmitted  in  two  ways — either 
through  the-transmission  of  ^'ibration  by  the  closel}'  knit  compact  bone  tissue 
or  through  the  incompressible  fluid  in  fluid-saturated  or  fluid-containing 
organs.  In  compact  bone,  with  the  missile  at  high  velocity,  In-  tlie  sudden- 
ness of  the  shock,  the  bone  is  disrupted,  and  the  osseous  pai-ticlcs  acting  as 
secondary  missiles,  are  forced  outward,  increas- 
ing the  disruption  and  traumatism  b}^  lateral 
transmission  of  the  energy  imparted,  (Fig.  1 7). 

With  the  bullet  moving  at  lower  velocity 
the  shock  in  bone  or  organ  is  less,  the  disrup- 
tion consequently  less,  and  with  still  lower 
velocity,  the  ball  may  enter  and  pass  through 
the  same  tissue  or  organ  witli  practically  no 
lateral  destructive  eff"ect.  In  a  broad  way,  the 
result  may  be  likened  to  the  difterence  in  effect 
produced  by  throwing  a  bullet  into  water  con- 
tained in  an  open  leaden  vessel  or  firing  the  bul- 
let into  it.  In  the  first  case,  the  bullet  will  enter 
making  slight  commotion,  and  that  mainly  upon 
the  surface  of  the  water;  while,  if  the  bullet  is 
fired  into  the  water,  the  containing  vessel,  even 
though  open  at  the  top,  will  be  completely 
destroyed  through  the  lateral  transmission  of 
energy  by  the  iiicompressible  fluid. 

When  the  shaft  of  a  bone  is  struck  at  short  range,  extensive  comminu- 
tion is  ])roduced  whatever  the  angle  at  which  the  bullet  may  impinge 
against  the  bone.  The  bullet  in  these  cases  produces  an  explosive  eftect  in 
accoi-dance  with  the  reasons  already  given,  (Fig.  17). 

This  effect  is  not  confined  to  the  bone  alone;  the  bone  fragments 
driven  out  into  the  surrounding  tissues  may  produce  extensive  traiunatisms 
of  the  subcutaneous  soft  parts,  and   may  even  be  driven   out  through   the 


Fig.  t7. — Lateral  traiisinisision  of 
energy  in  tlie  shaft  of  a  long- 
bone.  Diagrammatic;  modified 
from  Reger.  A  similar  effect  is 
produced  in  fiuid-containing  and 
fluid-saturated  organs. 


fifi 


KOXTdFA   HAV  IN  SPAMSH-AMEKICAN  WAH. 


wound  of  exit  and  into  a  nt'i>ihli(>riu,<i-  part.  In  a  case  of  this  sort  which 
came  under  the  observation  of  the  writer,  the  shaft  of  the  femur  was 
sliattered  for  five  incites  of  its  length  and  largely  reduced  to  bone  sand. 
Tlic  l)ullet  i)assed  through  l)()th  thigh  and  leg,  and  on  examining  the  wound 
in  tiic  latter,  bone  sand  and  several  fragments  of  bone  were  found  which 
had  Ix-eii  carried  through  the  first  wound  of  exit  and  driven  inti)  the  second 
wound  of  entrance  by  the  force  of  the  missile. 

In  another  in.stance  (Plate  XIV),  the  whole  of  tiie  distal  pail  of  a 
metacarpal  bone  was  blown  out  through  the  exit  wound,  which  was  but 
little  larger  than  usual. 


I'lix,'  I. — Krpldxivf'  effed  and  friietin'n  hy  cnntnct. 

John  T.  Siilliv;iii.  private.  Company  F.  Thirteenth  United  States  Infantry,  was 
Wdundcd  at  r>()ii-\-ii(l-  ranye  hy  a  Mau.ser  bullet,  which  passed  obliqaely  through  the 

hand,  fractured  the  third  metai'arpal  twne  by 
contact,  completely  destroyed  the  distal  end  of 
the  fourth  metacarpal  bone,  and  carried  out 
all  the  fragments  through  the  exit  wound. 
Though  all  the  fragments  of  the  fourth  meta- 
<arpal  had  been  driven  out  through  the  exit 
wound,  the  wound  was  little  larger  than  the 
wound  of  entrance,  and  only  by  use  of  the 
Hontgen  ray  would  it  have  been  suspected  that 
the  bullet  had  made  a  clean  resection  (Plate 
XIV). 

The  hand  was  dressed  with  the  tirst-aid 
dressing  and  the  patient  transferred  to  the 
general  hospital  at  Key  West.  On  arrival  at 
the  hospital  the  wounds  were  found  aseptic 
and  healed  quickly,  but  some  impairment  of 
function  resulted,  as  the  soldier  writes  in  No- 
vember, 1898:  "Motion  of  middle,  ring,  and 
little  tingers  much  restricted,  especial!}'  in 
Fiii.  18. — Dia>;raiu  exjilaiiatory  of  Plati'  flexion." 
XIV.     The  arrow  iuiUciitet'  the  coiirise 

<if  the  bullet.  lu  the  case  above  given,  the  radio- 

graph shows  tliat  the  third  metacarpal 
boue  had  been  shattered  bv  lateral  contact  of  the  bullet.  The  followinji'  case 
further  illustrates  this  interesting  form  of  fracture.  In  this  class  of  cases, 
though  the  ball  barely  grazes  the  bone,  the  energy  transmitted  laterally 
from  the  swiftly  nutving  missile  is  sufficient  to  produce  marked  coiuminutioii. 


PLATE   XIV. 


PLATE  XIV. 

Case  1,  .Section  IV. — John  T.  .Sullivan,  ]»rivatr,  ("(inipauy  F,  Tliirteentli 

United  States  Infantry. 

Ra(liogTa])li  of  left  hand,  viewed  from  the  back,  .showing  gunshot 
fracture  of  third,  and  foui'th  metacarpal  bones.  The  distal  end  of  the  third 
metacarpal,  fractured  by  contact;  the  distal  end  of  the  fourth  metacarpal, 
entirch-  dcstroved  by  the  missile. 


PLATE^IV. 


THE    HELIOTYPE    POINTING   CO..     BOSTON. 


PLATE   XV. 


PLATE  XV. 

Case  2,  Section  1\'. — Thoiuas  F.  ('aviinaiigli,  sergeant,  Troop  G, 
First  United  States  Volunteer  Cavalry. 

Radiograj)]!  of  i-ight  forearm,  viewed  from  the  front,  showing  Mauser 
hullct  fracture  "b}-  contact." 


PLATE  XV. 


Course 
of  the 
btdlet 


THE    HELIOTYPE    PRINTING    CO..     BOSTON. 


GUNSHOT  OF  THE  DIAPHYSES. 


67 


Cme  "Z. — Fracture  hy  contact;  operatirm.  at  field  hospital;  Huppvratwn. 

Thomas  F.  Cavaiiiiugli,  sergeant.  Troop  G.  First  United  States  Volunteer 
C'a\alrv,  was  wounded  at  a  range  estimated  at  under  400  yards  hy  a  Mauser  l)ullet 
\\lii(  h  passed  across  tli(>  front  of  the  right  forearm  at  its  lower  third,  severed  the 
tlexor  tendons,  grazed  the  periosteum  of  the  radius,  and  shattered  the  bone.  The 
traek  of  the  l)ullet  was  laid  open  at  the  field  hospital,  the  tendons  sutured  and  the 
wound  united  by  silk  sutures.  The  patient  was  transferred  to  the  General  Hospital, 
Key  West.  On  his  arrival  there,  pus  was  escaping  from  between  the  sutures  and 
the  wound  was  tense,  l)ulging,  and  nuich  inflamed.  The  sutures  were  removed  under 
an8esthe.sia  and  {\\k  wound  carefully  cleansed.  Owing  to  extensive  inflammation  and 
suppuration,  it  was  found  impossible  to  unite  the  tendons.  A  radiograph  (Plate  XV). 
was  taken  which  showed  excellently  the 
.shattered  condition  of  the  radiu.s  and  the 
longitudinally  disposed  fissures  between 
the  lione  splintcj-s.  The  wound  was 
treated  with  antiseptic  applications,  but 
had  not  entirely  healed  when  the  patient 
was  transferred  nortli.  .Vugust  22,  189^i. 
In  November  of  the  same  year,  the  sol- 
dier writes  that  he  has  no  use  of  the 
hand,  the  fingers  remaining  stiff.  The 
disability  is  probably  permanent. 

SUBCLASS  2.— FRACTURES  BY  PERFO- 
RATING BTTLLETS  STRIKING  THE 
BONE  IN  THE  MEDIAN  LINE. 

Case  J. — Comminuted  fracture  of 
femur  due  to  median  impact  of  hall; 
(ixeptic  vxjund;  recovei^  without  compli- 
cations. 

John  Robertson,  second  lieutenant. 
Sixth  United  States  Infantry,  wounded 
July  1,  by  a  Mauser  bullet,  which  entered 
the  anterior  surface  of  the  right  thigh 
ju.st  below  Scarpa's  triangle,  passed  from 
l)cfore  backward  through  the  femur,  and 
passed  out  directly  posterior.  There  was  profu.se  hemorrhage,  which  was  partly 
controlled  by  an  improvised  tourniquet  applied  by  an  officer  of  the  line.  Lieutenant 
Robertson  was  carried  to  the  rear  by  the  men  of  his  conmiand  and  while  thus  con- 
veyed, he  was  shot  in  the  left  sid(\  the  bullet  entering  just  below  th(»  inferior  angle  of 
the  left  scapula,  passing  beneath  the  muscles,  but  not  through  the  thoracic  wall,  and 
making  exit  just  below  the  left  nipple.  With  these  wounds  of  entrance  and  exit,  it 
was  at  hrst  thought  that  the  bullet  had  passed  through  tlu'  chest;  that  il  did  not  do  so 
was  due  to  the  extreme  outward  displacement  of  the  angles  of  the  scapuhe.  from  his 
being,  at  the  time,  lifted  by  the  armpits.  The  first  dressing  was  applied  at  the 
6648 7 


Fig.  19. — Diagram  uxiilauatory  of  Plate  XVI. 


68  rOntgen  ray  in  spanish-american  war. 

field  hospital.  Tin"  fnu'tui'o  was  dressed  hy  the  use  of  a  lono;  splint.  Tianst'erred 
July  ;>.  to  Third  Division  Hospital  and  two  days  later  to  the  Relief.  At  this  time, 
both  chest  wounds  were  healed.  The  thigh  wounds  remained  aseptie.  A  radiograph 
showed  great  comminution  and  displacement  of  the  fragments  by  overlapping 
(Plate  XVI). 

The  fracture  was  then  treated  by  confining  the  limb  upon  a  double  inclined 
plane,  consisting  of  a  hollow  posterior  splint,  made  of  the  sheath  of  the  leaf  of  the 
cocoa  palm,  tt)  which  was  added  an  anterior  thigh  splint  of  wire  gauze.  After 
dressing  the  limb  was  placed  in  a  sling.  Subseiiuently  a  Buck's  extension  was 
applied  and  finally  a  plaster  splint.  The  final  result  was  excellent,  for,  though  there 
was  H  inches  shortening,  the  callus  was  firm  (Plate  XVII),  and  the  position  and 
functional  use  of  the  limb  were  excellent. 

The  above  case  is  very  instructive,  as  it  illustrates  the  possibilities  of 
conservative  treatment  in  marked  comminution  of  the  shafts  of  long  bones 
where  the  woinid  is  aseptic. 

Excellent  examples  of  the  effect  of  the  small  cahber  bullet  when  it 
passes  directly  through  the  shaft  of  a  small  b(ine  of  the  hand  or  foot  are 
given  in  the  following  cases,  with  their  accompanying  radiographs : 

Case  Jf.. — Mauser  huUet  wound  of  Jingei\  ipith  eompound  fracture  of  second 
phalanx,  fourth  finger. 

George  H.  De  Revere,  private,  Companv  L,  Second  Massachusetts  Volunteer 
Infantry,  was  wounded  July  1,  at  unknown  range.  In-  a  Mauser  bullet  which  passed 
obliquely  through  the  fourth  linger  of  the  left  hand,  shattered  the  second  phalanx, 
and  then  passed  across  the  top  of  the  second  metacarpo-phalangeal  joint  of  the  middle 
finger,  producing  a  lacerated  wound  of  the  joint. 

The  patient  was  transferred  to  the  general  hospital.  Key  West,  where  the 
radiograph  shown  in  Plate  XVIII  was  taken.  The  bullet  had  passed  I'entrally 
through  the  finger.  The  wounds  of  entrance  and  exit  were  very  small.  They  had 
been  dressed  with  a  first  aid  dressing,  were  aseptic,  and  healed  quickly.  A  palmar 
splint  was  applied  and  the  fracture  treated  as  a  simple  one.  In  Novem))er,  1898, 
the  patient  wrote  that  there  was  complete  atikylosis  of  the  second  joint  of  the 
ring  finger. 

Ca.'se  5. — GunsJuit  fracture  all  noetatartsal  h<nu'.s  <f  foot ;  septic  wound;  anti- 
septic treatment ;  recovery  without  amputation. 

Carl  F.  Meyer,  private,  Company  D,  Sixth  United  States  Infantry,  was 
wounded  at  about  300  yards  range  by  a  Mauser  bullet,  which  passed  transversely 
through  the  foot  and  metatarsal  bones  from  without  inward.  First  aid  dressing 
was  applied  directly  after  receipt  of  the  injury.  Wound  redressed  three  days  later, 
at  which  time  foot  was  much  swollen  and  painful.  Patient  stated  that  he  was  at 
that  time  given  an  amesthetic  and  that  the  '•  foot  was  cut."  Was  transferred  to  the 
Relief  where  the  radiograph  (Plate  XIX)  was  taken.  The  wounds  were  treated 
with  antiseptic  dressings  and  finally  healed,  but  impaired  use  of  the  foot  lead  to 
discharge  for  disability.     Sixteen  months  after  the  injury,  the  second  radiograph 


PLATE   XVI. 


PLATE  XM. 

Cask  3,  Section  W. — Jolm  Robertson,  si'coiid  lieutenant,  Sixth 
Tnited  States  Intantn'. 

Hn(lio<jTai)li  of  rigiit  thiiili,  viewed  tVoiii  the  hack,  showing  Mauser 
liiillet  fraetui'e  with  extensive  (■(ininiiniition  (kie  to  vertical,  median  impact 
aii'ainst  the  shaft  of  tlie  femur. 


PLATE  XV!. 


-J-'rac/u/i 


ii.-.-*r*iji^K.«;  i:-li« 


■*''«Mfct-'     -  -HUi  lilJIUKg-*^..  ■£.^i-:i; 


THE    HELIOTVPE    PRINTING   CO.,    BOSTON, 


PLATE   XVII. 


PLATE  XYII. 

Case    3,    Section    IV. — John    Robertson,    second    lieutenant,     Sixth 
United  States  Infantry. 

.   Radiograph   of  riglit   tliigh,  viewed  from  the  l)ack,  sliowing  condition 
of  the  united  fracture  one  year  after  receipt  of  the  traumatism. 


PLATE  XVII. 


Callus 


THE    HELIOTYPE    PRINTING    CO..     BOSTON 


PLATE  XVIII. 


PLATE  XVIII. 

Case  4,  Section  l\. — George  H.  De  Revere,  private,  Coinpauv  L, 
Second  i\Iassachusetts  Volunteer  Infantry. 

Radiog-rapli  of  left  hand,  viewed  from  the  palmar  surface,  showing 
effect  of  the  ])assage  of  a  Mauser  Imllet  obliquely  through  a  jdialanx. 


PLATE  XVlll. 


THE    HELIOTYPE    PRINTING   CO.,     BOSTON. 


PLATE   XIX. 


PLATE  XIX. 

Cask  5,  Section  IV. — Carl  F.  Meyer,  private,  Company  U,  Sixth 
United  States  Infantry. 

Radiogra})hs  of  right  foot,  Anewecl  from  the  phmtar  .snrface,  showing- 
recent  and  remote  effects  of  the  passage  of  a  Mansei'  bnllet  through  the 
metacai-pal  bones.  The  passage  of  the  ball  from  witliin  outward  has  pro- 
jected bone  fragments  outward,  which  have  united  with  the  neighboring 
bones  and  fornieil  ii  Ixm^-  bridge  locking'  the  bones  tosjether. 


PLATE  XIX. 


..--i.  * 


THE  hCLlOTVPE  pfiiWTlHG  CO..  DOSTON. 


GUNSHOT  OF  THE  DIAPHYSES. 


69 


(Plate  XIX)  was  takeu,  and  is  of  interest  as  showing  tlie  condition  at  that  late 
date.  The  displaced  fragments  of  bone  had  all  united,  forming  a  solid  bony  bridge 
binding  the  metatarsals  together  in  innnoval)le  union.  The  occurrence  of  this 
result  would  seem  to  point  to  the  desirability  of  thoroughly  cleaning  the  wound  of 
all  bone  fragments  in  these  cases  in  order  to  prevent  the  impaired  function  which 
is  bound  to  occur  in  the  hand  or  foot  as  a  result  of  the  osseous  union  of  the  displaced 
fragments.  —  Vase  reportedly  Maj.  Louis  A.  Lii<hiril(\  mrgeon,  IJ.  S.  A. 

SUBCLASS  3.— FRACTURES  BY  BULLETS  STRIKIN(4  THE  BONE  TANGENTIALLY. 

Where  the  velocity  of  the  bullet  is  somewhat  diminished,  and  it  strikes 
a  bone  tang-entially,  the  amount  of  comminution  is  not  as  great  as  wlien 
the  ball  is  at  high  velocity  or  the  impact  is  medium  and  direct. 

When  the  impact  is  to  one  side  of  the 
median  line  of  the  bone,  the  splintering  is 
greatest  on  the  side  struck,  and  is  generally 
confined  to  that  side. 

Case  6. —  Oblique  fracture  of  radius;  wound 
explored  at  field  hosjMtal;  supjmration;  antiseptic 
treatment;  recovery. 

John  Bi'own,  prixate.  Troop  ( -,  Tenth  United 
States  Ca\'alry,  was  wounded  July  1,  at  200  yards 
range,  by  a  Mauser  bullet  which  passed  from  be- 
fore backward  through  the  forearm,  fracturing  the 
radius. 

He  was  transferred  to  the  general  hospital, 
Key  West,  where  he  arrived  five  days  after  the 
receipt  of  the  injury.  On  examination,  the  wound 
of  entrance  was  seen  to  have  been  enlarged  l)y  in- 
cision, and  the  patient  stated  that  it  had  been  oper- 
ated on  at  tlie  field  hospital,  l)ut  did  not  know  what 
had  been  done.  The  wound  was  suppurating,  there 
was  no  union,  and  there  was  marked  tension  on  the 
stitches.  The  wound  was  laid  open  under  ana\s- 
thesia,  thoroughly  cleansed,  a  fragment  of  bone 
7  cm.  long  and  2  cm.  wide,  was  removed,  and  an 
iodoform  gauze  drain  was  inserted.  With  the  finger 
in  the  wound,  it  was  found  that  best  apposition  was 

obtained  when  the  forearm  was  fully  extended  and  pronated.  A  long  posterior 
splint  was  applied  to  the  arm,  holding  it  in  that  position,  after  which,  examination 
with  the  fluoroscope  demonstrated  that  the  bones  were  held  in  correct  position.  A 
radiograph  taken  at  this  time  shows  the  position  of  the  bones  after  the  splint  was 
applied,  the  oblique  form  of  fracture,  the  loss  of  l)one  sustained  by  removal  of  the 
fragment,  and  that  the  bullet  had  passed  through  the  radius  at  its  outer  side  (Plate 
XX). 


Fig.    20.  —  Diagram     explauatuiy    ot 
Plate  XX.     «,  Place  of  impact  of 

bullet;    //,    site  of   removed   bone 
fi-agment. 


70  KONTGKN  RAY  IN  SPANISH-AMEKICAN  WAR. 

Th(M-c  wiifi  no  intluiiiniatoiy  roaction  or  rise  of  tcniporatun'  following  the 
operation.  The  wound  was  tliished  daily  witii  liydroo-en  peroxid(>  and  normal  salt 
solution,  and  was  entirely  closed  with  tirni  callus  at  the  seat  of  the  fracture.  Auoust 
U\.  when  he  was  transferred  to  the  transport  Son  Murcm.  January  4.  his  attending 
sui'geon  reports: 

"The  removed  hone  seems  to  have  lieen  largely  replaced  and  the  hand  and  forearm 
present  a  good  form.  The  joints  are  freely  movable,  passively  and  actively,  hut  all 
motions  are  feeble.  The  hand  hangs  seniitiexcd  on  the  wrist.  Adduction,  abduction, 
tlexion.  extension,  circumduction,  i)roiiation  and  suppination  are  ))resent  on  \()luntai'y 
ettort.  but  all  are  feelde.  Flexion  of  the  lingers  is  limited  to  the  second  and  tiiird 
joints:  the  grasp  is  very  feel)le.  The  thuini)  can  be  apiiroxiinatod  to  each  of  the 
lingers  suthciently  to  pick  up  a  pencil.  Init  there  is  little  power  in  it.  The  hand  is 
relatively  of  little  use,  absolutely  of  considerable."  The  patient  has  since  been  dis- 
charged for  disability  and  admitted  to  the  Soldiers'  Home  at  Washington.  D.  C. 


The  above  case  is  of  interest  from  its  excellent  ])roo;i-ess  under  antiseptic 
tveatniiMit.  As  the  wound  was  infected,  this  case  would  formerly  have 
re(|uired  imputation,  but  as  it  is,  the  arm,  while  disabled,  is  reported  to  be 
of  considerable  use;  certainly  better  than  no  arm  at  all.  As  the  bones 
united  firml\-,  the  resulting  disability  is  probably  mainly  due  to  the  injury 
to  the  soft  parts. 

Cai<:e  7. — Inmmpldf  fntvt u reof  radUm;  meptic  lomincl ;  ri'nulfhx/  impaired  motion 
due  to  cicatriiv. 

Dennis  B.  Watson,  private.  Troop  C,  First  United  States  Cavalry,  was  wounded 
July  1,  at  80(1  yards,  by  a  Mauser  bullet  whit'h  passed  from  behind  forwai'd  through 
the  outer  side  of  the  right  forearm,  fracturing  the  radius. 

Th(^  wound  was  dressed  with  the  tirst-aid  dressing.  Splints  were  ajiplied  and 
the  patient  transferred  by  the  steamer  Ir<i<ji«iix  to  the  general  hospital  at  Key  ^\'('st. 
On  his  arrival  the  wounds  were  aseptic  and  quickly  healed.  A  radiograph  was  biken 
which  showed  an  incomplete  fracture  with  right-angled  displacement  of  a  fragment 
of  l)one  (Plate  XXI). 

As  the  displacement  was  outward,  it  was  thought  that  the  rotation  of  the  radius 
would  not  be  interfered  with,  and  that  the  fragment  could  be  removed  later  if  neces- 
sary. The  patient  was  furloughed  August  7.  at  which  time,  though  motion  of  the 
forearm  was  limited,  there  seemed  to  be  every  indication  that  its  full  use  would  be 
restored.  Such  did  not  prove  to  be  the  case,  as  his  attending  surgeon  in  November 
wrote:  •"Soldier  has  not  full  use  of  the  arm  and  has  been  reconnniMided  for  discharge 
on  surgeon's  certificate  of  disability." 

The  patient  was  afterwards  discharged  for  disability  and  entered  the  Soldiers' 
Home,  Washington,  D.  C,  where  recent  examination  of  the  case  shows  that  the 
impaired  motion  is  due  to  the  injury  of  tiie  soft  parts  and  resulting  formation  of 
cicitricial  ti.ssue  in  the  track  of  the  ball. 


PLATE  XX. 


PLATE  XX. 

Case  6,  Section  IV. — Joliu  Browu,  ])rivate,  Troop  C,  Tenth  United 
States  C'avalry. 

RadiojiTapli  c>t'  left  forearm,  viewed  from  tlie  ])Osteri(>r  surface,  forearm 
su|)inated,  sliowing-  effect  of  the  passage  of  a  Mauser  bullet  through  the 
side  of  the  shaft  of  the  radius.  The  comminution  is  not  extensive,  one 
fragment  of  bone  onh-  having  been  separated  from  the  shaft  at  its  outer 
side. 


PLATE  XX. 


«l 


TmE    HELIOTVPE    PRINTINO   CO..    BOSTOh. 


PLATE   XXI. 


PLATE  XXI. 

Case  7,  Seci'idx  IV. — Dennis  H.  Wats()u,  private,  Trtxtp  C,  First  tlnitud 
States  Cavalry. 

liadiooTa])]i  of  ri<j;'lit  forearm,  viewed  from  the  j)osterior  surface, 
forearm  pi-onated,  showing  incomplete  fracture  and  right  angled  disphice- 
ment  of  a  bone  fragment  from  passage  of  a  Mauser  bullet  through  tlie  outer 
side  of  radius. 


PLATE  XXI. 


TMt  MCCtOTVf>E  PHINTING  CO..    BOSTON 


PLATE  XXII. 


6648- 


PLATE  XXII. 

Case  8,  Section  IV. — Albeit  B.  Swilt,  ])nv;ite,  Company  11,  Tenth 
United  States  Cavalry. 

Radiograph  ot"  upper  part  of  arm,  viewed  from  the  back,  showing 
long,  oblique  fracture  with  no  comminution,  ])roduced  by  Mauser  bullet 
wliicli  struck  the  shaft  of  the  humerus  at  its  outer  side. 


PLATE  XXII. 


THE,  MELIOryPE  PRINTING  CO.,    BOSTON. 


PLATE  XXIII. 


PLATE  XXIII. 

Case  9,  Section  IV. — Frauk  J.  Kraus,  })rivate,  Compauv  B,  Six- 
teenth United  States  Infantry. 

Radiograph  of  the  lower  part  of  tlie  nglit  thigh,  viewed  from  the  pos- 
terior surface,  showing'  an  obhque  fracture  of  the  femur  bv  a  ])enetrating, 
Mauser  bullet.  The  bullet  is  seen  behind  the  inner  condyle  lying-  butt  end 
foremost. 


PLATE  XXIII. 


Fracture  - 


Mauserbullef- 


THE  MELIOTVPF  PRINTING  CO..   BOSTON. 


GUNSHOT  {^F  THE  DIAPHYSES.  71 

Offfi,,  ^. — Ohliijiir  friKiiirr  of  JniiiimiK  from  fmirfoifiiil  impnctofhill;  aKi'pfif 
■wound. 

Albert  B.  Swift,  private,  Company  H,  Tonth  Cavalry,  was  twice  wounded 
July  1.  One  bullet  passed  through  the  ulna  at  lower  third,  shattering  the  l)one,  and 
a  resection  was  made  at  the  tield  hospital.  The  second  bullet  passed  from  l)efore 
backward  through  the  arm  at  the  upper  third,  striking  the  humerus  at  its  outer 
side  and  producing  a  long,  oblique  fracture  with  no  comminution  (Plat(>  XXH). 
The  arm  was  inuuobilized  and  union  occurred  without  trouble.  Discharge  followed 
for  disability  resulting  from  the  injui'v  to  the  ulna.  —  Ca>«-  Jiistonj  coiiijiihd  from 
rec(rr<lx  hi  Sirr(/<'im-G<')ii'ri(r>i  Ofjii'e, 

CLASS  2.— FRACTURES  BY   UNDEFORMED   BULLETS  HAVING  SUFFICIENT 
VELOCITY  TO   PENETRATE  ONLY. 

Fractures  bv  bullets  liaving  greatly  reduced  velocity  are  usually 
characterized  \>\  small  amount  of  bone  splintering.  The  fractures  closely 
resemble  the  simpler  forms  of  fracture  produced  by  inchrect  violence,  and 
this,  apparently,  whether  the  bullet  passes  through  the  bone  or  fractures  it 
b}'  impact. 

Cai^e  9. — Fracture  offi'uiur  hy  ricorlnf  holl.  iiitcrihg  huff  tud  forciiioKf ;  (isej>fw 
wound. 

Frank  .1.  Kraus,  private.  Company  B,  Sixteenth  United  States  Infantry,  was 
wounded  July  l,at  a  supposed  range  of  500  yards  by  a  Mauser  bullet,  which  entered 
the  body  just  to  the  right  of  the  tip  of  the  coccyx.  The  wound  was  dressed  and  the 
patient  transferred  to  the  Belief,  where  a  radiogi-aph  was  taken.  The  radiograph 
(Plate  XXIII),  showed  an  uncommiiuited  oblique  fracture  of  the  right  fenuu-  in  the 
lower  third,  and  the  bullet  lodged.  l)utt  end  foremost  just  behind  the  inner  condyle. 
The  line  of  fracture  was  from  above  downward  and  from  behind  forward,  and  had 
apparently  been  made  by  the  bullet  impinging  against  the  bone.  Recovery  was 
uneventful,  but  the  limb  was  shortened  2  inches,  and  the  soldier  was  finally  dis- 
charo-ed  for  disability. —  Ca.se  history  v(t]n])iled  froiu  records  in  Surgeoii-Geiiendi's 
Office. 

Case  10. — Fracture  of  /nnueriis  hy  impact  (f  Mauser  hdlet;  aseptic  wound; 
resulting  disability. 

Clarence  Reed,  private,  Compyny  H,  Tenth  United  States  Infantry,  July  1,  erect 
position.  500  yards  from  tiring  line,  received  two  gunshot  wounds.  He  was  trans- 
ferred to  the  Relief  where  the  following  wounds  were  found:  One,  a  flesh  wound,  per- 
forating right  arm,  producing  paralysis  of  the  arm;  the  other,  an  entrance  wound  over 
third  rib,  anterior  part  of  thorax,  was  lacerated,  triangular  in  shape,  base  toward 
right  side,  about  1  inch  wide  at  base  and  2  inches  long.  Left  arm  showed  extravasa- 
tion from  clavicle  down  to  wrist.  Oblique  frat-ture  of  upper  part  of  humerus. 
Radiograph  (Plate  XXIV)  shows  Mauser  bullet  close  to  inner  side  of  humerus  at 
point  of  fracture,  entrance  evidently  right  anterior  surface  of  thorax.     July  12, 


72  U(")NT(iEN  KAY  IN  SPAMSH-AMEKK'.W  WAR. 

angului-  splint  of  palm  hark  applied,  exteiuliiii;'  t'loiii  shouhicr  to  wrist.  Kadiograph 
showed  IK)  other  bullets,  and  position  oi  splint  very  yood.  July  lio.  wounds  healed. 
Considerahlo  eallus  about  fraeture  and  partial  union. 

November  17. 1899,  diseharged  on  .surgeon's  oertitieate  of  disability  for  "motoi- 
and  sensory  paraly.sis  and  trophie  changes." — C'a«e  history  compUcd  fram  li<iKji/f,i] 
recdi'ch  of  lioKjiitdl  x/i/'j>  Relief  and  records  of  the  Surgeon-  GenrraT  k  Ojfir, . 

In  tlie  al)ove  case,  the  bullet  must  have  traversed  the  anterior  thoracic 
wall  and  entered  the  arm  behind  the  axillary  folds,  struck  the  humerus  on  its 
inner  side,  and  fractured  it.  The  utter  impossibility  of  locating-  this  liullet 
by  means  of  a  i)robe  is  evident. 

Case  11. — Fracture  of  u/na  vit/i  moderate  comminutUm  l>y  2)en,et rating  Man-ser 
huUct;  aseptic  wound/  huJlet  located  hy  Riinfgeu  ray  and  removed. 

John  Casey,  private.  Company  C,  Thirteenth  Cnited  States  Infantry,  was 
wounded  July  1.  at  an  estimated  range  of  -100  yards,  by  a  penetrating  Mauser  V>ullet, 
which  entered  the  posterior  and  outer  aspect  of  the  forearm  at  the  lower  third.  The 
wound  was  dressed  with  a  tirst-aid  dressing  and  the  patient  transferred  to  the  general 
hospital  at  Key  West.  Examined  there  July  (5;  wound  small  and  a.septic.  Fracture  of 
ulna  at  middle  third.  Examined  with  the  Huoroscope.  but  the  static  machine  from  the 
excessive  dampness  of  the  atmosphere  was  not  working  well,  and  what  was  thought 
to  be  a  bullet  was  dimly  seen  directly  over  the  fracture.  This  was  cut  down  upon, 
July  9.  under  aseptic  precautions,  when  the  supposed  bullet  was  found  to  be  a  frag- 
ment of  bone.  This  was  removed  and  the  wound  healed  by  first  intention.  Subse- 
quent search.  M'ith  better  light,  showed  the  bullet  lodged,  butt  end  foremost,  near 
the  internal  condyle  of  the  humerus  beneath  the  flexor  profundes  digitorum.  It  was 
removed  July  28.  The  ball  had  evidently  ricochetted.  turned  end  for  end.  and  with 
reduced  velocity  entered  the  arm  and  pas.sed  through  the  ulna.  The  ulna  was  broken 
transversely  and  some  small  fragments  of  bone  separated  (Plate  XXV). 

CLASS  3.— FRACTURES  BY  PENETRATING,  DEFORMED  BULLETS. 

Penetrating,  deformed  bullets  appear  to  produce  fractures  of  \\\v  sliaft 
of  the  long-  bones  which  are  similar  in  form  to  those  produced  h\  unde- 
formed  bullets,  unless  the  deformation  of  the  bullet  is  excessive.  Like  the 
penetrating,  undeformed  bullets,  slightly  deformed  bullets  produce  oblique 
fractures  with  little  sijlintering,  while  greatl}'  deformed  and  nuishroomed 
])idlets  produce  marked  connninution  of  the  bone. 

Case  12. —  Comminuted  fracture  of  femur  hy  Jlmiscr  hulht  ^^  niiixliroouicd"  ht/ 
ricocJut ;  lone  fragments  removed;  woimd  treated  atdisepticaUy ;  recimry  iritlund 
amputation. 

Daniel  J.  (iravos,  private.  Company  M.  Eleventh  United  States  Infantry,  was 
wounded  at  Mayaguez,  P.  R.,  August  10,  1898.  Wound  of  entrance,  iiuiei-  side, 
lower  third,  right  thigh.     Fenuir  fractured;  no  wound  of  exit.     Patient  was  trans- 


PLATE  XXIV. 


PLATE  XXIV. 

Case  10,  Section  IV. — Clarence  Reed,  private,  Company  H,  Tenth 
United  State.s  Infantry. 

Radinyraph  of  proximal  jjart  of  the  left  hnmerns,  viewed  from  the 
back,  showinji' fracture  of  the  humerus  produced  byim])act  of  a  penetrating 
Mauser  bullet  against  the  inner  side  of  the  bone.  The  bullet,  which  has 
been  turned  by  the  impact,  is  seen  lying  against  the  inner  side  of  the 
humerus. 


PLATE  XXIV. 


fracture — - 


Mauser\ 
6ullet  i 


■■!-.T-<miJ!''r't-i 


THE    HELIOTYPE    PRINTING   CO.,     BOSTON. 


PLATE  XXV. 

Case  11,  Section  TV. — Jolm  Casey,  private,  Coinpauv  C,  Thiiteentli 
United  States  lufantr}-. 

RadiogTaph  of  right  forearm,  viewed  from  the  anterior  sm-face,  showing 
fractm-e  of  the  uhia  by  a  penetrating,  Maiiser  bullet.  The  comminution  is 
moderate  and  does  not  extend  for  from  the  line  of  fractiu-e. 


PLATE  XXV. 


DrrccT 

in 

KATE. 


FRkCTURC. 


THE  HCLIOTVPE  PRINTING  CO..  BOSTON. 


PLATE   XXVI. 


PLATE  XXVI. 

Case  12,  Section  IV.— Dauiel  J.  Graves,  private,  Compauy  M,  Elev- 
enth Uuited  States  Infautry. 

Radiograph  of  right  thigh,  ^^evred  from  the  back,  showing  extensively 
comminuted  fracture  of  the  femur  by  a  penetrating,  Mauser  bullet  mush- 
roomed by  ricochet.  The  liuUet  is  seen  lying  at  the  outer  side  of  the  bone 
tlii'ough  which  it  lias  passed. 


PLATE  XXVI. 


Fracfan;- 


Jluuserhaf/el 
mus/t/  vomPit 


THE    MELIOTYPE    PRINTING    CO..     BOaTON. 


PLATE   XXVII. 


PLATE  XXVII. 

Photograph  of  bone  t'rag-ments,  natural  size,  in  the  case  of  Daniel  J. 
Graves,  pri\ate,  Company  M,  Eleventh  United  States  Infantry. 


PLATE  XXVII 


1^ 


\ 


* 


FRACTURES  BY  DEFORMED  BULLETS. 


73 


torred  to  RiIJit\  whcro  radiogTaph  (Plate  XXVI)  showed  fracture  by  a  imishroouied 
hullot;  comminution  great. 

The  bullet  had  pa.ssed  through  the  bone  and  lay  on  the  outer  side  of  the  fenuir 
13  cm.  above  condyle.  August  IS,  the  bullet  (No.  8,  Plate  II)  and  several  fragments 
of  bone  were  removed  through  an  incision  made  on  the  outer  side  of  the  thigh. 
The  fragments  removed  are  shown  in  Plate  XXVII,  and  this,  with  the  radiograph, 
shows  the  great  amount  of  bone  s])liiitering  which  occurs  in  fracture  by  a  mush- 
roomed bullet.     A  plaster  splint  was  applit^d.     The  patient  was  transferred  from  the 


ComtninuteU  Irac/u 


¥       \LoJ.atcl  cje formed 


Fig.  21. — Diagram  exjilunatory  of  Plate  XXVI. 

Rd'uf  to  the  Long  Island  College  Hospital.  He  finally  recovered  with  2i  inches 
shortening  of  the  limb,  and  was  discharged  for  disability. —  Case  hlKfonj  from 
rixofdx  ill  the  Surf/eon- GeiieraPx  Ojfici'. 

The  following  case  is  of  interest  in  tliat  the  feinni-  was  liadly  shattered 
and  two  deformed  bullets  were  embedded  in  the  limb.  One  bullet  was  a 
Mauser  (No.  6,  Plate  II);  the  other  the  lead  core  of  a  brass-jacketed  l)ullet 
from  which  the  jacket  had  been  toi'n  by  ricochet.  Whether  the  fracture 
was  made  by  one  or  both  bullets  it  was  iinoossible  to  determine. 


PLATE  XXVIII. 

Case  13,  Section  l\. — Georg-e  I'arker,  corporal,  Cuiui)auy  E,  Tweiity- 
f'ourth  United  States  Infantrv. 

RadiooTapIi  of  lower  part  ot'  ritjht  tliia'h.  vicwcil  tVoin  the  back,  sliow- 
iiig-  a  iiuicli-coiniuiuuted  fracture,  two  lodged  bullets,  and  a  fragment  of 
metal.  One  missile  is  the  much-deformed,  lead  core  of  a  l)rass-jacketed 
bullet:  the  other  a  deformed,  Maiiser  bullet.  It  is  not  known  by  which 
missile  the  fracture  was  made. 


PLATE  XXVIII. 


Comminuted  fracture. 


Lead  core  of  brass  jacketed- 
bullet. 


Fragment  of  metal. 


Deformed   Mauser   bullet. 


A  nee  joi?it. 


THE    HELIOTYP6    PRINTING    CO   .     BOSTON. 


PLATE  XXIX. 


PLATE  XXIX. 

Case  14,  Section  I\'. — John  A.  Barouoski,  private,  Company  C,  Eighth 
United  States  Infantry. 

Radiograph  of  left  leg,  viewed  fi'oni  the  front,  showing  long,  oblicjue 
fractiu'e  of  the  tibia,  made  by  a  brass-jacketed  bullet,  a  fragment  of  the 
mantle  of  which  is  lying  at  the  side  of  tlie  tibula. 


PLATE  XXIX. 


■^^f*^<  vv  ..^  ^...  -.*.■  f. » 


THE    MELIOTrPE    PRiNTINC    CO..     SOSTON. 


GUNSHOT  OF  THE  DIAPHYSES.  75 

removed  at  the  field  hospital  and  the  leo-  put  up  in  plaster.  Suppuration  supervened. 
and  the  patient  was  transferred  to  the  Relief,  where  the  Rontoen  lay  showed  a  piece 
of  the  jacket  of  the  l)ullet  still  in  the  tissues,  and  that  the  hall  had  produced  a  long, 
oblique  fracture,  extending  upward  from  the  point  of  impact  of  the  huilet  nearly  to 
the  condyles  of  the  tibia  (IMate   XXIX).— t'^/.sr  hlxtory  compiled  ft'om   reeordu  in 

the  S\iii'(/e(iii-(Ti'iicriir>i  O'lfice. 

CLINICAL     CONCLUSIONS. 

Oonsideration  of  jiunshot  trauiiuitisins  of  tlie  .sliaft  of  long-  bones,  as 
shown  by  the  Rontgen  ray  in  connection  with  tlie  ultimate  outcome  of 
the  cases,  points  indubitably  to  the  conclu.sion,  that  infection,  or  noninfec- 
tion  of  the  wound  .should  influence  treatment,  rather  than  the  amount  or 
extent  of  bone  comminution. 

In  noninfected  wounds,  extensive  comminution  is  not,  as  a  rule,  an 
indication  for  operative  interference  of  -.mx  kind.  ( )cclu.sive  dressings  and 
immobilization  give  assurance  of  the  best  possible  results.  Where  there 
is  considerable  comminution,  shortening  of  the  limb  will  probably  occur  as  a 
result  of  the  connninution  and  the  disjilacement  of  the  bone  fragments.  But 
excellent  functional  use  of  the  limb  may  be  I'estored,  uidess  the  lesion  of 
the  soft  parts  is  extensive  and  motion  is  restricted  by  the  formation  of 
cicatricial  connective  tissue  in  the  traumatic  spaces. 

Where  infection  exists,  removal  of  the  cause  under  ase])tic  or  antisep- 
tic precautions  is  indicated.  In  such  cases,  complete  cleansing  of  the  wound 
and  removal  of  all  loose  bone  fragments,  followe<l  l)y  drainage  and  anti- 
septic dressings  and  irrigation,  will  usually  suffice,  and  excision  or  amputation 
will  onh-  ha\'e  to  be  resorted  to  in  extreme  cases. 


GUNSHOT  FRACTURES  OF  THE  EXTREMITIES  OF  LONG  BONES 
AND  OF  CANCELLOUS  BONES  GENERALLY. 

GUNSHOT    OF    THE    EPIPHYSES. 

Roiito-eu  v;\y  examinations  liave  demonstrated  that  tlie  effect  of  the  mod- 
ern small-cahl)er,  jaeketed  projectile  on  the  extremities  of  long-  Ixnies  is  mark- 
edly different  from  its  effect  on  the  shaft.  This  is  undoubtedly  due  to  the 
difference  in  the  structure  of  those  parts  of  the  bone.  In  the  shaft,  compact 
tissue  ])redominates,  and  this  dense  tissue  transmits  the  vibrations  produced 
by  the  imi)act  of  the  bidlet  more  readily  tlian  the  less  dense  tissue  of  the 
extremities,  wliei-e  the  loosely  knit  cancellous  tissue  forms  the  main  pai't  of 
the  bone.  In  compact  tissue,  the  vibrations  set  U])  b\-  the  bullet  are  trans- 
mitted with  enough  force  to  cause  molecular  vibrations  sutticient  to  jwoduce 
solutions  of  continuity  at  some  distance  from  the  point  of  impact  of  the 
missile.  In  cancellous  tissue,  the  forcible  A-ibi'ations,  from  the  nature  of  tlie 
tissue,  are  transmitted  but  a  short  distance  and,  in  conse(iuence,  solutions  of 
continuitv  take  place  only  within  a  comparatively  short  <listance  from  tlie 
point  of  impact.  As  the  amount  of  destruction  in  the  shaft  de])ends  u\nn\ 
the  conditions  of  impact,  so  in  the  extremities,  the  amount  of  injury  done  l)y 
the  ball  varies,  but  to  a  nuich  less  degree  than  in  the  shaft.  The  connninu- 
tion  is  never  as  great  and,  frequently,  the  ball  siin])l\-  cliannels  the  bone, 
or,  when  nearlv  spent,  end)eds  itself  without  jiroducing  -awv  splintering  or 
comminution. 

Caxe  1. — ^Lduner  hulht  lndqrtl  liiilt-tinJ  farcmoxf  hi  fihiu  :  hullif  laaitnl  hi/ 
Rdnf(ii'V  ray  and  i\-iiurred. 

John  J.  L.  Tiiylor.  private.  Company  E,  Tpntli  I'niti'd  States  (';ivah-y,  July  1. 
1898.  occupyiiiii'  u  jjroiK'  position  ahoiit  .">0(l  yards  from  opposite  tirin<;-  line,  reeeived 
perforating  wound  riyht  ankle,  about  '.i  inches  above  internal  malleolus.  Entriuice 
wound  jjunctured.  No  wound  of  exit.  Considerable  o'dema  and  eccliymo.sis  about 
ankle  joint:  movement  of  joint  very  i)ainful.  Kiintgen-ray  picture  (l'lat(^  XXX) 
shows  the  l)ullet  embedded  in  the  bony  part  of  the  internal  malleolus,  apex  pro- 
truding, soldier  evidently  having  been  exposed  to  ricochet  tirint>-. 

July  J2:  Operation.  Incision  made  •>  inches  lon<;'  directly  over  internal 
malleolus;  skin  and  subcutaneous  tissue  divided  and  bullet  felt  distinctly  by  tinii'er. 
Soft  parts  separated  by  blunt  dissection  and  build  exposed,  hi'iniy  embedded  in 
bone.  Only  with  i;reatest  difliculty  and  by  usinj;-  lion  foreejjs  could  missile  be 
moved.  It  proved  to  l)e  a  .Mauser.  The  cavity  in  the  l)one  was  perfectly  smooth, 
76 


PLATE  XXX. 


PLATE  XXX. 

Case  I,  Section  V.— Jolm  J.  L.  Taylor,  i)rivate,  Company  E,  Tenth 
United  States  Cavalry. 

RadiogTa|)li  sliowing-  ]\rauser  liullet  embedded,  Imtt-end  foremost,  in  tlie 
lower  end  of  the  tibia,  with  no  splintering-  of  the  bi>ne. 


PLATE  XXX. 


jyiauser  bii//e/  - 


# 


THE  MELIOTYPE  PRINTIHG  CO.,   BOSTON. 


PLATE  XXXI. 


platp:  XXXI. 

Case  2,  Section  V. — Dtiuiel  B.  Rayinoud,  private,  Companv  D,  Six- 
teeutli  United  States  Infantry. 

Radiograph  showing  shrapnel  bullet  with  small  fragments  of  bone 
about  it,  lying  in  the  thigh  behind  the  femur,  through  which  it  jjassed, 
making  a  clean-cut  hole.  The  shadows  near  the  femur  are  from  the  iodo- 
form dressing.     A  safety  pin  in  the  dressings  is  outlined  on  the  femur. 


PLATE  XXXI. 


Iodoform  yauzr\ 

an  d  safdypin    J        *' 


/Shrajjttel  hullel  ■ 


jafc: 


TMC  MELIOTYPE:  printing  CO..    BOSTON. 


GUNSHOT  OF  THE  EWPHYSES.  77 

as  if  drill  had  been  used.  No  spliiiterino-  of  l)one.  Wound  was  cleansed  with  weak 
solution  of  l)ichloride  of  mercury  and  skin  brought  together  by  deep  silkworm-gut 
sutures. 

July  14,  prhnary  union;  pain  and  cedenia  having  disappeared. 

July  22,  a  slight  discharg(>  of  jmrulent  material.  Wound  opened  at  upper  part 
and  iodoform  gauze  introduced.     No  uedeuia  al)out  ankle.     No  pain. 

Jul}'  2i,  wound  clear. 

July  26,  transferred. —  Vase  histonj  from  hospital  ship  Relief. 

That  the  slow-moving-,  lead  bullet  can  at  times  produce  a  clean  perfora- 
tion of  the  extremity  of  w  hone  is  sliown  by  the  following-  case: 

Vase  ^. — Peiforatimi  oflmoer  end  (ffermrr  hy  a  shrapnel  haJl;  aseptic  vynind; 
missile  located,  hy  Tlimtgeri  ray  and  remolded. 

Daniel  B.  Raymond,  private.  Company  D,  Sixteenth  Infantry,  was  wounded 
July  1.  Entrance  wound  small,  dressed  with  first  aid  dressing.  Transferred  to 
Relief,  where  radiograph  was  taken  which  showed  that  the  missile  was  a  shrapnel 
(Plate  XXXI). 

Transferred  to  Long  Island  College  Hospital  where  the  following  history  is 
given:  The  l)ullet  entered  the  thigh  at  the  lower  third,  and  by  Kontgen  ray  was  shown 
to  be  located  behind  the  head  of  the  tibia.  An  incision  was  made  over  the  point 
indicated  in  the  picture  and  the  l)ullet  was  found  with  several  small  fragments  of 
bone  it  had  pushed  before  it.  In  the  condyle  of  the  femur  was  a  round,  clean-cut 
hole  extending  completely  through  the  bone.  A  small  amount  of  turbid  fluid  was 
found  at  the  site  of  the  bullet.  The  wound  was  closed  without  drainage.  Complete 
recovery  resulted. —  Vase  history  from  hosj^ital  ship  Relief  ((ad  Long  fsland  Vollege 
Hospital. 

Cases  like  the  above  are  probably  comparatively  uncommon,  as  the 
lower  end  of  the  shaft  of  the  femur  is  composed  of  quite  compact  tissue  and 
is  usually  completely  fractured  or  splintered.  Perforation  of  the  upper  end 
of  the  feniui',  witliout  fracture  or  comminution,  is  probably  much  more 
common.  The  following  case  and  radiograph  sIioav  the  small  amount  of 
connninution  produced  by  a  Mauser  bullet  passing-  thi-ough  the  femur  in 
the  region  of  the  great  trochanter.  From  the  conflicting-  evidence-  it  is 
probable  that  tlie  fracture  produced  by  the  ball  was  not  complete  at  lirst, 
but  afterwards  became  so. 

Vase  3. — Mamer  liallet  fractwe  of  uj>per  extrem,ity  of  feimir;  tnnind  aseptic; 
recovery  tcifhout  anq)idatio)i. 

Theodore  Wint,  major  Tenth  United  States  Cavalry,  July  1,  1898,  i)efore 
Santiago,  San  Juan  Hill,  shot  in  left  thigh  from  before  backward,  Mau.ser  striking 
cover  of  small  morocco  pocket  book,  which  it  pierced;  ball  did  not  pass  out  of 
trousei-s  t)ehind  after  having  cut  through  the  thigh.  Line  of  flight  was  at  an  angle 
to  surface  of  thigh,  so  that  entrance  was  larger  than  exit  wound.     Direction  of 


PLATE  XXXII. 

Case  5,  Section  V. — Theodore  J.  Wiut,  iiuijor,  Tenth  Cavalry. 

Radiograph  of  the  upper  part  of  the  left  thigh,  viewed  from  the  back, 
showing  Mauser  bullet  fracture  of  the  femur  in  the  neighborhood  of  the 
iiitcrti-ochanteric  line.  There  appears  to  l)e  considerable  loss  of  bone 
substance  in  the  neighborhood  of  the  great  trochanter,  and  an  oblicpie 
fracture  with  no  tissuring.  It  is  ])robable  that  the  ball  perforated  the 
bone  and  so  weakened  it  that  it  afterwards  fractured. 


PLATE  XXXII. 


THE    MEt-IOTYPE    »R1NTING   CO..     BOSTON. 


PLATE  XXXITI. 


PLATE  XXX I II. 

Plate  XXXIII,  Section  V. — Earnest  Knowles.  ]n-ivate,  C'ompaiu-  D. 
Twenty-first  United  States  Infantry. 

Radiographs  of  left  knee,  viewed  from  tlie  inner  side,  and  from  the  l)ack, 
sliowing  Reming-toii  l)ullet  which  has  passed  downward,  backward,  and 
inward  and  lodged  in  the  upper  part  of  the  tibia. 


PLATE  XXXIII. 


0 


THE    HELIOTVPE    PRINTING    CO.  ,     BOSTON. 


(U'NSHOT  OF  THE  Kl'Il'IlYSES.  7;t 

ol'  oiif-lialf  iiK-ii.  KiKT  s(ill  slightly  swuilcn.  soiiicwhiit  slill.  I)iii  tU-x'um  siill 
g-nidually  iiu-rwising-.  Crulchcs  on  Scptciiil.cr  fl.  ("uii  hear  some  wcio-ht  on  injured 
leg.  —  Cdx,'  hiatdni  coiiijiilid  fruii,  m-nrilx   'm   Si,  rij' ni, -(;,„,  niPs  Ofice. 

On  accuiiiit  of  its  caiicelloiis  structui'i-,  tlic  upper  end  of  tlie  tibia  is 
frequently  pierced  witlioiit  coiniiiinution  ur  complete  fracture.  The  two 
foUoAviui)-  cases  are  of  inteivsl  in  that,  in  eacli  case,  the  missile  wounded  the 
kneejoint  and  passed  from  above  (lowiuvard  Into  the  tibia  without  producini-- 
any  destruction  of  Ixme  otlier  than  clean  penetration. 

CoAse  J4.. —  \\oiiiiil  iif  l,ii<  I  jdiiif :    jh-rt'(iriifi(iii   uf  fihia;    itsrjiiii-    irniiiid;   reconeni 

witJwat  ciiliipl iciit miis. 

Lewis  (inuicr.  pri\!itc.  Coiiipany  E,  Sixtccntli  I'nitcd  Slates  Infantrv.  wounded 
by  a  ^hiusei-  laillet  at  San  Juan.  July  M.  IS'.IS.  distance  unknown.  I'rojeetile  entered 
outer  aspect,  rijj-lil  kneejoinl.  l>et\veen  tiie  outer  condyle  and  head  of  tihia.  and  i'aiu'-in<'- 
downward  and  inward  lludugli  the  head  of  the  tibia,  it  emerged  :it  tlu'  inner  side  of  the 
leg  2  cm.  b(d()w  tin'  head  of  the  tibia.  The  limb  was  placed  on  a  posterior  splint. 
Was  sent  to  the  base  hospital  at  Siboney,  Jidy  10. 

Examination  February  4.  1900:  The  wound  of  entrance  is  marked  by  a  round 
scar  the  size  of  the  jjrojectile;  the  exit  wound  by  a  scar  a  tritie  larger.  Flexion  of 
knee  somewhat  ini])aired.  Radiogra))!!  shows  slight  exostosis  on  iinier  surface  of 
tibia  at  site  of  exit  of  bullet.  i)robal)ly  due  to  callus  formed  about  small  specula 
of  bone  displaced  outward  from  exit  wound  in  lione. —  Citx,-  hinfori/  hi/  _Maj.  Lou  if  A. 
LaGwrde,  Surgeon.   United  Stairs  Acini/. 

The  next  case  iihistrates  how  a  bnUet  of  laryc  caliber  uia\-  penetrate 
the  upper  em!  of  the  tibia  without  producing  anvfractni'e  Ix'vond  the  direct 
line  of  its  course.  It  also  shows  the  good  result  whicli  nia\'  be  obtained  in 
gunshot  wound  of  the  knee,  even  when  made  In  a  large,  ricochetted  missile, 
the  good  result  undoubtedly  being  due  to  the  contiinunl  antiseptic  treatment 
employed. 

Case  5.  —  tiiiiislint  nf  km,  li,/  rii;,fli,t  R,;ini  iii/tiiii,  ixdiber  .Jfii.  ■wifhiji'iietrutiini  uf 
til,i,i. 

Earnest  Knowles,  privati>,  Company  I).  'I'wenty-tirst  Fnited  States  Infantr^v, 
was  wounded  October  'I'd.  189!t.  at  San  Cristobal,  Calaniba.  V.  I.,  at  about  250  yards 
range  by  a  Remington  bullet.  He  was  kneeling  at  the  time  and  the  bullet  struck  the 
ground  just  in  front  of  his  left  knee,  ricochetted,  passed  through  khaki  trousers, 
apparently  without  causing  loss  of  sLd)stance  of  the  latter,  and  struck  the  knee  in 
front  of  the  external  condyle  of  I  he  fenuir.  grazecl  that  bone.  ))assed  through  tile 
joint  and  downward,  inwai'd.  and  liarkward  into  the  upper  end  of  liie  tibia.  A 
tirst-aid  dressing  was  immediately  applied  and  (he  patient  transported  to  hospital. 
The  external  wound  was  so  large  that  two  lingers  could  easily  lie  inserted  into  it. 
The  wound  was  cleaned,  drained,  and  iiiigated  witJi  luitiseptic  solution.  Healing 
6648 10 


80  kontgp:n  kay  in  si'amsm-ameiucan  a\"ak. 

was  complete  in  about  seven  weeks.  Soldier  Avas  discharged  for  disability  on  account 
of  impaired  motion  of  the  joint,  and  he  entered  the  Soldiers"  Home.  Washington,  D.  C. 
Radiograph  taken  May  14.  11*00.  shows  large  l)ullet  lodged  in  upper  and  back 
part  of  tibia  (Plate  XXXIII).  From  this  localization,  the  bullet  was  subsequently 
removed  from  the  body  of  the  bone  by  Maj.  Ix)uis  A.  LaGardi'.  Surgeon.  I'nited 
States  Army. 

In  the  uext  case,  the  radiugTaj)!!,  thuugli  not  taken  until  six  nuaitlis 
after  the  receipt  of  the  injury,  clearly  shows  the  ))erforation  made  by  the 
bullet  (Plate  XXXIV).  The  radiograph  indicates  that  the  fracture  was 
not  complete,  though  the  j)atient  stated  that  he  could  feel  the  bony  frag- 
ments move  on  each  other  when  pressure  was  made  near  the  wound  at  the 
time  of  the  injury.  The  short  range  at  wdiicli  the  wound  was  inflicted,  10 
feet,  would  give  the  niaxinutm  of  destructive  effect  in  osseous  tissue,  and 
that  the  comminution  was  not  greater  must  be  ascribed  to  the  looseness  wnth 
which  the  bony  tissue  is  knit  in  the  upper  part  <>f  the  tibia. 

Cdxe  6. — Perfiiratioii  of  tthta  In/  KriKj-Jurtiinxrii  nt  i<lii>rt  ratuji . 

Private  AVesley  Kibby,  Company  H,  Twenty-fourth  Infantry,  while  on  duty 
at  Presidio,  Cal.,  June  25,  1899.  was  accidently  shot  by  a  comrade.  Distance  was 
not  over  10  feet.  Bullet  was  a  Krag-Jorgensen.  Entered  left  tibia  4  cm.  below 
patella,  and  emerged  from  most  prominent  portion  of  calf.  l)elow  bend  of  knee. 

Examination  February  4. 1900:  Wound  of  entrance,  transverse  oval.  1  byf  cm. 
Wound  of  exit,  oval,  puckered,  retracted,  '2  by  1  cm.  The  man  says  that  he  could 
feel  the  bony  fragments  move  on  each  other  when  pressure  was  made  near  wound. 

Treatment:  ,Dres.sing  and  immobilization;  wounds  healed  in  three  weeks:  able 
to  walk  in  eight  weeks  with  aid  of  cane;  left  ankle  and  foot  remained  Aveak.  and  sole 
of  foot  felt  numb,  with  occasional  needle-like  pains  shooting  through  it.  He  has 
weakness  of  all  muscles  of  posterior  aspect  of  leg;  also  of  extensor  hallucis,  and  loss 
of  sensation  over  anterior  two-thirds  of  plantar  surface  of  foot.  Some  .stiffness  of 
foot  and  ankle  still  present,  and  he  is  unable  to  walk  without  aid  of  a  cane.  —  Case 
history  hy  Muj.  Louis  A.  LaGardc.  surgeon.  Zhiited  Sfafi-x  Army. 

The  small  amount  of  comminution  produced  bv  the  Mauser  bullet  in 
passing  through  the  extremities  of  the  bones  of  the  arm  and  forearm  is  shown 
in  the  following  cases. 

Case  7. — Separation  of  olecranon  hy  ImUet  without  comtninution. 

Theodore  H.  Lubold.  private.  Company  I.  Sixteenth  P(>nnsylvaiiia  Vohinteei- 
Infantry,  was  shot  while  retreating  during  the  skirmish  near  Guayamo,  Augu.st  9. 
The  l)ullet  entered  the  right  arm  al)ove  the  olecranon  process  and  emerged  from  the 
extensor  side  of  the  forearm  between  the  radius  and  the  ulna.  The  Kontgen  ray 
I'eveals  the  presence  of  a  fragment  of  the  t)ullet,  or  its  mantle,  lodged  in  the  wound, 
and  that  the  olecranon  was  separated  from  the  shaft  without  comminution  (Plate 
XXXV). — Cane  history  from  records  in  Sun/ti/n-Oencrars  Office. 


PLATE  XXXIV. 


PLATE  XXXIV. 

Plate  XXXIV,  Section  V. — Wesley  Kibby,  jirivate,  I'onipiui}-  H, 
'l\venty-toiirtli  Tiiited  States  Intaiitrv. 

Ka(li()L;i-ai)li  of  left  knee,  viewed  from  the  hack,  sliowinii-  perforaticm  ot 
upper  end  of  til)ia,  made  Ity  Ivrag-Jorg-eusen  at  short  range. 


PLATE  XXXIV. 


PCRFORdTTOM. 


1- 


THE    MELIOTVPE    PRINTING   CO..    BOSTON. 


PLATE   XXXV. 


PLATE  XXXV. 

Case  3,  Section  V. — Theodore  H.  Liibold,  Company  I,  Sixteenth 
Pennsylvania  Volunteer  Int'antry. 

Radiograph  of  right  elbow,  \newed  from  its  inner  side,  showing  separa- 
tion of  the  olecranon  with  no  fissuring  of  the  fragments,  and  a  small  frag- 
ment of  metal  lower  down  in  the  forearm. 


PLATE  XXXV. 


THF    HEIJOTVPE    PRINTING   CO.,    BOSTON. 


PLATE   XXXVI. 


PLATE  XXXVT. 

Case  6,  Sectiox  V. — Horace  K.  Devereaux.  lieutenant.  First.  United 
States  Cavalry. 

Radiog-raphs  showino-  fracture  of  the  lower  end  of  the  radius  by  a 
lodged  Mauser  bullet.  There  is  separation  of  (jnite  a  large  external  frag- 
ment, but  the  connninution  does  not  extend  up  the  shaft.  The  hnllet  has 
been  displaced  hx  the  flexor  tendons  and  is  seen  lying  ])oint  upward  in 
front  of  the  i-adins.  From  its  position,  it  is  probal)lc  tliat  it  entered  the  ])art 
butt  end  foremost. 


PLATE  XXXVI 


I 


THE    HELiOTYPE   PRINTING   CO.,    BOSTON. 


GUNSHOT  OF  THE  EPU^HYSES. 


81 


Case  8.—Mavs,'r  hxUet  fmrf,,,;  nf  ,nii,r  nnidijlr  ,,f  hiivimis  v!fl,  no  rxfcLsioii 
offractmri'  of  ahuft  ofhone. 

Riilph  Barkinaii.  private,  t'oiiipany  K,  Second  Ma.ssaclmsetts  Volunteer  Infant ly, 
was  twice  wounded  at  Siboney,  Cuba,  July  1.  l.s'.i;).  One  bullet  entered  the  left  leo-; 
the  other  passed  through  the  lower  third  of  the  left  arm.  The  patient  was  trans- 
ferred to  the  R,-J!,t'.  where  a  radiogi-aph  was  taken  whit'li  showed  that  the  outer 
condyle  was  separated  from  the  shaft,  but  that  there  was  no  splintering  of  the  bone 
extending  up  the  shaft.  The  patient  was  traii.sferred  to  St.  Peter's  Hospital.  15rook- 
lyn,  N.  y.,  and  discharged  from  there  July  29,  1899,  "cured."— 6W///.>,7'r;/7/ />«//, 
Tecorclx  III  Suriii'oii-lreni'i'dVK  Ofici'. 

Ill  tlie  tollowing-  case  of  fracture  of  the  distal  end  of  tlie  radius,  tlie 
bullet  was  proljahly  traveling-  at  low  velooit}-,  and  entered  the  ])art,  l)utt  end 
foremost.  The  ainouur  of  comminution  was  not  great, 
the  fracture  being-  mainly  the  separation  of  a  rathei-  large 
external  fragment. 

Case  9. — Fnicture  oflmoer  md  of  radvm  hy  Ma/user  hdlet; 
infection  of  wound;  Jocallzatum  of  hull rt  hy  Eontgen  ray,  and 
removal;  antiseptic  treatment;  recmv-r-y  'without  innpiitatirm. 

Hoi-aee  K.  Devereaux,  lieutenant.  First  United  States  Vol- 
uuteer  (.'a\ali-y.  was  wounded  June  27,  at  200  yards,  by  a  Maaser 
bullet,  which  entered  the  dorsal  aspect  of  the  left  forearm  over 
the  ulna.  A  first-aid  dressing  was  applied  twenty  minutes  after 
the  receipt  of  the  injury.  The  patient  was  transferred  north 
on  the  OJirMe  and  entered  Roose\elt  Hospital,  where  he  came 
under  the  care  of  Dr.  Robert  Abbe,  who  radiographed  the  fore- 
arm (Plate  XXXVI). 

At  that  time,  the  forearm  was  in  a  condition  of  ditfuse  cellu- 
lits  and  suppin-ation,  the  wound  having  been  infected.  Dr.  Abbe 
removed  the  bidlet  July  18,  and  the  case  progressed  to  excellent 
recovery  with  wrist  motion  about  one-foui-th  and  rotation  of  the 
forearm  about  one-half  the  norniui.  Though  the  bullet  lodged, 
the  patient  believed  that  it  had  not  ricochetted.  ])ut  ascribed  its 
low  velocity  to  defective  powder.  The  position  of  the  bullet, 
however,  indicated  that  it  had  i-icochetted  and  entered  butt  end 
foremost,  and  that  its  position — oblique  to  its  line  of  (^ntrance — 
was  due  to  pressure  from  the  overlying  tendons  of  the  forearm. 


1m 


c 

J  Jiagiuiu  ex- 
planatory of  Plate 
XXXVI.  o,  Flex..r 
tendon;  6,  fractured 
radius;  c,  place  of 
entrance   iif   luillet. 


GUNSHOT   OF  THE   CANCELLOUS  BONES   GENERALLY. 

The  effect  of  the  modern  bullet  upon  the  hones  of  the  wrist  and  the 
cancellous  bones  of  the  foot  and  face,  is  vevx  similnr  to  its  effect  upon  the 
epi))liyseal  ends  of  the  long  bones;  i.  e.,  guttering,  or  perfornfion,  with  small 
extent  of  commiuutiou. 


82  liCiKTGEN  KAY  IN  SFANISII-AMEKK'AX  WAR. 

Case  10. — Pi'rfonition  of  »-s  c((/c/!<  hi/  JLiks,  r  luUct. 

Private  John  F.  Muvphj'^,  Company  C,  Fourth  United  States  Infantry,  was 
wounded  at  unknown  ranoe  by  a  Mauser  bullet,  whieh  passed  from  behind  forward, 
and  from  above  downward,  through  the  left  os  cak'is.  The  wound  healed  readily, 
Init  pain,  located  beneath  the  heel,  persisted.  A  ladiooraph  was  taken  which  showed 
a  sharp,  bouj'  spur  projecting  downward  from  the  under  surface  of  the  os  calcis. 
This  exostosis  was  undoubtedly  a  caUus,  formed  about  small  bone  fragments,  which 
had  T)een  forced  outward  from  the  bone  at  the  place  of  exit  of  the  bullet.  The 
weio-ht  of  the  body  being  brought  upon  this  spur  when  walking,  caused  the  disability. 
The  bullet  made  so  clean  a  perforation  of  the  bone  that  there  was  no  evidence  of 
fragmentation  of  the  os  calcis  with  the  exception  of  the  small  fragments  forced  out 
at  the  wound  of  exit.  The  exostosis  was  removed,  November  19,  1898;  the  wound 
healed  by  first  intention,  and  the  patient  returned  to  duty. 

The  following-  case  gives  the  result  of  a  Krag-Jorgensen  bullet  fracture 
of  one  of  the  metacarpal  bones.  It  is  of  interest  in  that  the  hand  was 
directlv  over  the  muzzle  of  the  gun  when  it  was  accidentally  discharged, 
and  though  the  whole  charge  passed  through  the  hand,  the  entrance  and  exit 
wounds  were  small  and  the  bone  lesion  slight. 

Case  11. — Perfcrration  of  trapezium,  hy  Kraq-Jorgenseti  hillet. 

Pri\-ate  August  Blume.  Company  C,  Twenty -first  United  States  Infantry,  acci- 
dentally discharged  his  rifle  July  2,  the  bullet  and  whole  discharge  passing  through 
the  paini  of  his  hand.  Radiograph  showed  that  the  IjuUet  had  perforated  the  tra- 
peziiua,  throwing  out  only  a  small  fragment.  The  entrance  and  exit  wounds  were 
small  and  there  was  nothing  in  the  appearance  of  the  part  different  from  that  seen 
in  wounds  received  at  long  range.  The  wound  healed  by  first  intention,  but  full 
use  of  the  hand  was  not  restored,  as  cicitrical  tissue  in  the  wound  caused  some 
limitation  of  motion. 

The  following,  a  case  of  clean  perforation  of  the  os  calsis  by  what  was 
supposed  to  be  a  Remington  brass-jacketed  bullet,  like  case  5  of  this  section, 
shows  the  clean  perforation  of  cancellous  bone  by  the  larger  missiles. 

Case  12. — Perforatum  of  os  calcis  hy  Remington  huUet. 

Samul  S.  AYentworth,  private.  Battery  E,  First  Artillery,  wounded  June  13, 
1899,  at  Zapote  Bridge,  near  Manila,  P.  I.,  presumably  by  a  Remington  bullet,  as 
the  wounds  of  entrance  and  exit  were  somewhat  larger  than  those  made  by  the 
Mauser,  and  the  enemy,  so  far  as  known,  were  using  Remington  rities.  The  bullet 
passed  from  without  inward  through  the  heel,  perforating  the  os  calcis.  The  wound 
did  not  heal,  and  three  months  after  the  receipt  of  the  injury,  an  operation  was  done 
and  a  piece  of  legging,  a  piece  of  stocking,  and  three  small  pieces  of  bone,  were 
removed.  "Wound  has  opened  twice  since  and  small  amount  of  pus  escaped.  \Yas 
discharged  for  disability  December  29, 1899,  aud  seen  by  the  writer  in  January,  1900, 


PLATE  XXXVII. 


PLATK  XXXVIT. 

Case  12,  Section  \'. — SnnuH'l  S.  AN'cntworrli,  private,  lintTciN  K,  ?''irst 
United  States  Artiller}  . 

RadioiiTiiph  of  left  foot,  viewed  from  tlie  inner  side,  showing-  Imllet 
(Remin<itou)  perforation  of  the  os  cahMs.  Though  the  radiograph  was 
raken  several  months  after  the  recei))t  of  the  injm-y,  the  callus,  if  it  has 
tilled  the  ])erforatiiMi,  is  sfill  transparent  to  the  Ki'mtgen  rays. 


PLATR  XXXVII. 


X.^ 


THE    HELIOTVpe    PRINTING   CO..    BOSTON. 


PLATE  XXXVIII. 


PLATE  XXXVIII. 

Case  13,  Section  I. — Couelius  L.  Eagau,  pi-ivate,  Cuiiii)any  K,  First 
Nebraska  Volunteer  Infantry. 

Kadiograph  of  face,  viewed  from  the  riglit  side,  showing  Remington 
bvillet  in  the  right  antrum  of  Highmore. 


PLATE  XXXVIII. 


THE    MEUOTVPE    PRINTING   CO.,    BOSTON. 


(iUxNSHOT  OF  CANCELLOUS  BONES.  88 

when  the  radiog-mph  (Plate  XXXVII),  which  .shows  a  clean  j)erf()ratioii,  was  taken. 
At  this  tiuie,the  wound  was  healed  and  the  condition  of  the  part  and  use  of  the  limb 
appeared  to  be  excellent,  though  some  pain  extending  up  the  leg  was  complained  of. 

Owina'  to  tliu  cancelliius  structure  of  the  bones  of  the  face,  gunshot 
traumatisHis  of  that  region  resemble  those  of  the  cancellous  bones  generally. 

Case  13. — Penetrdfing  gunshot  of  focc  Inj  R<:iiiniiji<)ii  Jmlltt.,  odilhcr  .JfJJ  ;  loaili- 
zation  hy  Rontgen  rwy;  removal. 

Cornelius  L.  Eagan,  private,  Company  K.  First  Nebraska  Volunteer  Infantry. 
Gunshot  wound  of  right  side  of  face,  received  February  5,  189SI,  at  Block  House 
No.  7,  Philippine  Islands.  Wound  over  left  eyebrow,  one-half  inch  from  iimer 
canthus.     No  wound  of  exit. 

Symptoms:  Partial  deafness  of  right  ear  and  total  blindness  of  right  eye. 

Ophthalmoscopic  examination :  Choroiditis  and  retinitis  with  atrojjhy .  the  selera 
showing  through  large  areas  in  lower  portion  of  field.  Left  eye  normal  in  appear- 
ance. Anchylosis  of  jaw.  Only  .slight  separation  of  teeth.  No  pain,  and  only 
slight  swelling  of  the  right  side  of  the  face. 

Diagnosis:  Foreign  body  in  the  right  face. 

Treatment:  Was  radiographed  in  April  and  again  in  May  (Plate  XXXVIII), 
after  which  an  effort  was  made  to  remove  the  bullet.  Operation  May  31,  by  Major 
Matthews.  Incision  was  made  along  nose  to  mouth  by  median  line,  and  transversely 
across  the  face  to  li  inches  from  the  ear.  Soft  parts  retracted  and  search  for  bullet 
was  made,  but  was  unsuccessful.  Second  operation,  August  16,  1899,  by  Maj.  A.  C. 
Girard.  The  same  incision  was  made.  The  inferior  surface  of  the  antrum  was 
chisseled  through  and  the  ball,  which  proved  to  be  a  Remington  .46,  flattened,  and 
somewhat  ragged,  was  removed.  The  skin  incision  Avas  closed  l)y  subcuticular  gut 
suture  and  healed  excellently. —  Cat>e  history  hy  Maj.  A.  O.  Girard,  surgeon,  U.  A'.  ^1. 

CLINICAL   CONCLUSIONS. 

The  same  conclusions,  relative  to  treatment,  obtain  in  fractui'es  of  the 
extremities  of  the  long  bones,  as  hold  in  fractures  of  the  shaft.  Infection  or 
noninfection  of  the  wound,  rather  than  the  amount  of  comminution,  indicates 
v^^hether,  oi-  n()t,  the  wonnd  sliould  be  treated  expectantly  or  otherwise. 
From  a  standpoint  of  the  amount  of  traumatic  destruction  done  by  the  ball, 
expectant  and  conservative  treatment  is  even  more  indicated  in  gun.shot 
injuries  of  the  extremities  than  in  similar  injuries  of  the  shaft  of  tlic  Ijones. 
This  is  due  to  the  fact  that  observation  shows  that  the  amount  of  conuui- 
nution  is  much  less  and  the  size  of  the  fragments  nuich  smaller,  in  gunshot 
fractures  of  the  extremities  of  the  long  bones,  than  in  gunshot  fractures  of 
the  shaft. 


84  KONTGEN  KAV  IX  SPANISH-AMERICAN  WAR. 

Nor  (li>e>i  the  fact  that  joints  arc  involved  necessitate  a  diverg-auce 
troMi  the  rule  of  expectant  treatment. 

Infection  of  the  wound  or  extensive  destruction  of  the  soft  parts  may 
necessitate  operative  interference.  But  with  ordinary  penetrating  or 
perforating  wounds,  occlusive  dressings  and  immobilization  have  been 
followed  bv  best  results.  When  this  treatment  is  supplemented  by  rapid 
transportation  to  base  or  general  hospitals  where  operation  can,  if  neces- 
saiy,  be  done  with  adequate  aseptic  or  antiseptic  technic,  the  best 
possible  results  may  be  expected. 


VI. 

RADIOGRAPHIC  TECHNIC. 

Proper  manipulation  of  the  apparatus  is  most  important  in  Rr)ntgen- 
ray  work;  tor,  with  imperfect  methods,  imperfect  or  negative  resuUs  are 
obtained,  and  serious  injury  to  the  [jatient  by  burns  may  be  intiicted. 
Maximum  radiation  in  the  tube  dejjends  upon  supplying  the  tube  with  the 
current  best  adapted  to  its  ))articular  condition.  To  obtain  a  suitable 
current,  proper  adjustment  nmst  be  made  of  the  difterent  working  parts  of 
the  a])paratus,  and  knowledge  of  technical  details  by  which  such  adjust- 
ments are  made  is  essential  to  success.  As  the  static  and  the  coil  machines  are 
entirely  different  in  construction,  the  means  by  which  radiation  is  influenced 
necessarily  differs  in  each,  and  the  metliod  of  operating  each  type  of  ajjpa- 
ratus  has  to  be  separately  considered. 

THE  STATIC  MACHINE. 

In  operating  the  static  machine,  special  attention  has  to  Ije  given  to 
the  condition  of  the  machine  relative  to  atmospheric  conditions,  to  the 
sjieed  of  rotation  of  the  plates,  and  to  the  adjustment  of  the  spark  gaps 
and  the  tube. 

In  the  static  machine,  efficient  output  is  deiiendent  in  large  measure 
upon  the  absence  of  all  dampness  and  dust  from  the  interior  of  the  case. 
To  keep  the  plates  clean,  they  nmst  be  occasionally  carefully  wiped.  To 
protect  the  machine  as  much  as  possible  from  moisture,  it  should  l)e  kept 
in  a  well  lighted  and  ventilated  room,  with  windows  provided  with  inside 
wooden  shutters,  which  can  be  closed  when  fluorosco})ic  examinations  are 
to  be  made  during  the  daytime.  To  insure  the  absence  of  luuuidity  within 
the  case,  it  is  usually  necessary  to  keep  dishes  of  calcium  chloride  within  it. 
When  this  is  done,  fresh  chloride  shouhl  be  placed  within  tlie  case  whenever 
any  moisture  accumulates  in  the  dishes  holding  the  old  chloride.  In  very 
damp  climates,  the  edges  of  the  frame  of  the  case  where  the  glass  is  inserted 
should  be  thickly  and  carefully  covered  with  tliick  petrolatum,  to  insure 
against  passage  of  the  damp  exterior  air  into  the  interior  of  the  case.  As 
a  precaution,  to  prevent  loss  of  current,  the  front  of  tlie  machine  should  be 
carefully  wiped  dry  each  time  before  using  i1. 


6648 11 


85 


86  K(')NT(iKX  KAY  IN  SPANlSll-AMKKIC'AN  WAR. 

As  surtiririit  s|k'C'(1  and  steady  rotation  of  tlu'  plates  is  essential  to 
hig-hest  eilii-ienc\-,  tlic  machine  is  best  oi)erated  by  some  kind  of  motor,  the 
speed  of  which  can  l)c  re>iulated.  Keo-ulation  of  s])eed  is  necessary:  in  that, 
when  a  tube  is  Avorkinj^-  iit  its  highest  etheienc}'  with  the  anode  glowing 
l)roperly,  diminution  of  speed  will  decrease  the  output  of  rays;  and  an  increase 
of  speed,  while  not  increasing  the  efKcieut  output,  may  impair  the  life  of 
the  tube. 

To  operate  an  eight  or  ten  plate  static  machine  satisfactorily,  a  motor 
of  one-fourth  liorse))ower  is  rcipiired. 

An  electric  motor  of  some  relialjle  make  is  best  for  use  when  an  elec- 
trical current  is  avaihiblc,  as  such  a  motor  can  be  easily  and  quickly  adjusted 
for  speed.  Unfortunately,  electrical  currents  can  not  always  be  oljtained  in 
military  hospitals. 

When  electrical  current  is  not  available,  water  motor  can  be  used  and 
will  work  efficiently,  provided  the  water  pressure  where  the  motor  is  placed 
is  not  lower  than  twenty  pounds  to  the  square  inch.  Such  a  motor  has  the 
advantage  of  ccMuparatively  low  original  cost  and  of  being  free  from  run- 
ning expense. 

Where  motor  power  is  not  available,  manual  power  may  be  used,  and 
witli  it  excellent  work  can  be  done;  but  such  labor  is  extremely  tiring, 
even  when  relays  of  men  are  emjiloyed.  Where  such  jjower  lias  to  be 
depended  u]ion,  a  tandem  bicycle  attachment  for  running  the  machine  would 
probably  be  very  useful. 

CROOKES    TUBES 

As  the  electrical  cuiTents  supplied  ))y  the  static  and  the  coil  machines 
are  quite  different;  tubes  are  specially  constructed  for  each  type  of  machine. 
As  a  rule,  these  tubes  work  best  only  with  the  tyjie  of  machine  for  which 
constrttcted,  and  can  not  be  used  with  other  types  without  loss  of  efficiency 
or  danger  to  the  tube. 

Relative  to  their  excitation  and  radiation,  tubes  are  divided  into  two 
classes — low  tubes  and  high  tubes. 

By  a  low  tube  is  meant  a  tube  which  is  readily  excited  to  radiaticm  by 
a  comparatively  small  ciuTent,  and  which  when  excited  does  not  proiluce 
rays  of  great  penetration.  Tulles  when  tirst  received  from  the  manufac- 
turers are  generally  in  tliis  conditi(Hi.  With  such  tubes,  the  bones  when 
viewed  by  the  fluoroscope  appear  quite  dark,  anrl  metallic  objects  can  not 
be  seen  through  tliem.  Such  tubes  are  unfitted  for  radiography  of  tliick 
parts.     They  should  be  eujployedfor  i'a<liography  of  the  thin  parts  and  the 


KADKMiKAl'HlC  ■I'KCIIXIC.  «7 

extremities  of  thin  individuals  until  they  Iteconic  liio-hcr.  All  tubes  liuve  a 
"life."  A  tube,  at  first  low,  by  use  gradually  iH-eonies  so  resistant  to  the 
electric  current  that  it  can  no  lon<>-er  be  illuniinated.  For  tliis  reason,  in 
using  a  tube,  the  opei-ator  should  earetulh-  ex^nnine  ,ts  workiui;'  with  a 
fluoroscope  to  determine  its  condition  and  to  \vh;it  use  it  is  best  acUipted.  A 
ready  method  of  determininfj-  the  condition  (if  a  tube,  is  to  see  whether  or 
not  a  coin  or  cuff  button  held  against  the  forearm,  can  be  easih-  seen  through 
the  radius.  If  not.  the  tul)e  is  a  low  one  and  should  only  be  used  for  work 
for  which  such  a  tube  is  adapted,  or  it  may  be  raised  to  a  hig-her  vacuum  b\ 
suitable  manipulation. 

A  low  tube  may  be  raised  by  continued  use  or  by  I'evei'sinu' the  current: 
but  in  reversing'  the  current,  care  should  be  taken  not  to  continue  the 
reversal  too  long-  a  time  or  the  tube  may  be  ruined.  This  i-eversal  of  the 
current  is  easily  managed  in  the  coil  machines  by  reversing  the  switch  le\(!r; 
but  in  the  static  machine,  it  is  necessary  to  close  the  current  and  rever.se 
the  tube. 

High  tubes  are  distinguished  l)y  recpuriug  a  large  or  maximum  cui-reiit 
to  excite  them,  and  by  producing  rays  of  great  penetration.  With  such 
tubes,  the  bones  appear  gray,  and  metallic  objects  are  readily  seen  through 
them.  A  ready  test  for  such  a  tube  is  abilit-v^  to  see  with  the  fluoroscojx^  the 
shadow  of  a  watch  tlirough  a  man's  skull.  A  tube  which  will  give  this 
result  is  fitted  for  chest  and  body  work  and  for  radiograi)h\-  of  such  dee]) 
parts  as  the  pelvis  or  hip  joint. 

Eventually,  siu-h  ;■.  tube  will  become  so  high  as  to  resist  all  attempts  to 
illuminate  it,  even  with  powerful  current  and  careful  adjustment. 

When  this  occurs,  the  vacuum  can  be  lowered  by  subjecting  tlie  tube 
to  heat,  by  baking  it  in  a  hot-air  oven,  or  carefully  heating  it  over  a  Bunsen 
burner  or  alcohol  lainp.  When  the  tube  no  longer  responds  to  these 
mani]5ulations,  it  can  be  returned  to  the  maker  for  reexhaustion  and  will 
then  again  work  satisfactorily  for  some  time. 

MANIPULATION   OF  THE   TUBE  TO  SECURE   ITS   MAXIMUM    RADIATION. 

Maximum  radiation  of  any  tul)e  is  obtained  l)y  supiihing  it  with  an 
electrical  current  of  tension,  quantity,  and  rapidit)'  of  oscillation,  best 
adapted  to  its  vacuum.  In  the  static  machine,  this  is  arrived  at  h\  the  use 
of  the  spark  gaps  and  the  velocity  of  rotation  of  the  plates.  Spark  gaps, 
or  current  interrupters,  are  metallic  rods  attached  to,  and  nio\al>le  upon, 
each  sliding  pole  of  the  nuu'hine.      Wv  attaching  the  wires  leading'  to  tiie  tube 


88  KONTGEX  KAY  TX  SPANISH- AM ERK'AN  WAR. 

to  tlu'se  iippliances,  the  current  may  l»e  carried  direct  to  the  tube,  or  maybe 
interrupted  and  caused  to  pass  throug'h  any  desired  distance  of  air  space. 
The  spark  gaps  and  their  proper  manipuhition  are  a])sohitely  necessary  to 
secure  i)roper  radiation  from  most  tubes.  All  tubes,  however,  do  not 
require  their  use.  Tubes  of  high  vactium  and  great  penetration  frequently 
work  best  when  the  wires  are  coimected  direct  to  the  poles  of  the  machine. 
With  low-vacuum  tubes,  it  is  necessar}-  to  pass  the  cuireut  through  an  air 
space;  the  length  of  air  space  depending  upon  the  condition  of  the  tube. 
The  h)wer  the  tube,  the  farther  the  spark  gaps  must  be  separated;  so 
increasing  the  air  space  through  which  the  current  has  to  pass.  With  the 
tul)e  adjusted  and  the  spark  gaps  closed,  the  machine  should  be  started  into 
rapid  action  and  a  fluoroscopic  examination  made.  If  the  bones  appear 
gray  and  transparent,  the  tube  is  probably  working  at  its  best  and  no  spark 
gap  is  required. 

Trial,  however,  sliould  be  made  to  ascertain  if  the  fluorescence  may 
not  be  increased.  To  do  this,  separate  the  positive  spark  gap  and  observe 
the  result.  Then  separate  the  negative  gap  and  adjust  the  gaps  to  the 
distance  which  gives  the  best  radiation  from  the  tube.  This  distance 
may  be  a  ver>-  small  fraction  of  an  inch,  or  it  may  be  an  inch  or  more. 
This  can  only  be  determined  by  a  trial,  which  takes  but  a  few  moments. 
With  the  spark  gaps  properly  adjusted,  the  radiation  depends,  to  a  certain 
extent,  upon  the  rapidity  of  revolution  of  the  plates.  Rathation  is  at  its 
best  when  the  entire  anode  glows  with  a  dull  red  color.  When  this  glow 
is  obtained,  the  revolution  of  the  plates  should  not  be  increased;  as  over- 
heating of  the  anode  and  destruction  of  the  tube  may  result,  with  no  ade- 
quate compensation  in  the  way  of  increased  radiation. 

THE    COIL    MACHINE. 

In  the  coil  machine,  radiation  in  the  tube  is  regulated  by  the  condenser 
and  vi])rator. 

The  condenser  is  placed  in  the  mahogany  base  upon  which  the  coil  is 
placed,  and  it  greatly  increases  the  power  of  the  coil. 

The  condenser  is  made  in  sections,  and  is  connected  to  a  series  of  four 
plugs  on  the  top  of  base,  by  which  it  is  possible  to  use  any  portion  or  the 
whole  of  the  condenser  at  will.  It  will  be  found  that  some  focus  tubes  will 
wox-k  best  when  only  using  a  few  sheets  of  the  condenser,  whereas  other 
focus  tubes  require  considerably  more  condenser,  and  in  some  cases  it  is 
necessary  to  plug  it  all  in. 


RADIOGRAPHIC  TECHNIC.  89 

In  order  to  pluy  in  tliu  (■uiuleiiser,  the  plug  sliould  l)e  inserted  l)etween 
the  two  parallel  Hat  brass  strips,  in  the  hole  provided  for  that  inn-jjose; 
whereas,  if  any  part  of  the  condenser  is  not  re([uired  for  use,  that  particu- 
lar plug-  shoidd  be  iuserte<l  in  one  of  tlu'  foui-  lioles  in  the  middle  of  tiie 
long  brass  strip. 

The  coils  furnished  witli  tlie  batter}-  sets  are  operated  by  a  vil)rator 
wliit'h  lias  a  special  adjustment  b}'^  which  the  periodicity  of  the  vibi-ation 
can  be  varied  at  will.  As  tubes  vary  in  effect  relative  to  the  periodicity  of 
the  vibrations,  these  sliould  be  regidated  bj'  the  adjustment  made  foi-  this 
purpose,  so  that  the  maximum  radiation  of  the  tube  may  be  obtained. 

A  combined  switch  and  pole  changer  is  mounted  at  tlie  end  of  the  coil  for 
reversing  the  current  and  for  opening  the  circuit  when  desii-ed,  and  a 
rheostat  is  employed  for  controlling  the  (piantitA-  of  ciuTciit  passing  to  the 
coil. 

When  using  the  coil,  close  the  pole-changing  switch  and  adjust  the 
contact  sci-ew  of  the  vibrator  (previously  loosening  the  clamping  nut  of  the 
same),  until  a  steady  yellow-green  fluorescence  occurs  in  the  tube  and  then 
retighten  the  clamping  nut.  If  the  discharge  is  passing  through  the  tube 
in  the  right  direction,  the  body  of  the  tube  (embracing  tlie  space  between 
the  flat  platinum  anode  and  the  concave  aluminum  catliode)  will  1)e  fllled 
with  a  uniform  fluorescence  and  that  part  of  the  tube  above  the  flat  plati- 
num anode  will  remain  in  shadow.  If  no  shadow  appears,  the  pole-changing 
switch  should  be  reversed.  In  using  a  focus  tube  for  the  first  time,  the 
greatest  care  should  be  taken  not  to  allow  the  flat  platinum  anode  to  become 
red-hot;  for  if  it  is  allowed  to  remain  at  this  temnerature  for  any  consider- 
able length  of  time,  the  inside  of  the  glass  tube  will  blacken  through  particles 
of  platinum  being  thrown  off  against  the  inner  surface  of  the  tube.  Also, 
the  high  temperature  will  raise  the  vacuum  in  the  tul)e  considerably  and 
shorten  the  working  life  of  the  tube,  while  there  is  danger  of  the  lube  being- 
broken  down  entirely  if  the  platinum  anode  is  allowed  to  become  bright 
red-hot. 

The  best  result  with  the  tu])e  can  be  ol)tained  when  the  platinum  anode 
is  at  the  temperature  of  a  very  dull  red  (invisible). 

When  first  lighting  up  a  new  focus  tube,  use  as  little  current  as  possible 
until  it  is  ascertained  that  the  current  is  passing  in  the  right  direction,  as  it 
injures  the  efficiency  of  the  tube  if  a  heavy  current  is  sent  in  tlic  wrong 
direction. 

After  considerable  use,  the  vacuum  in  a  foi'us  tube  rises  oii  account  of 
tendency  of  the  electrodes  and  glass  to  absorb  the  residual  gas,  until  linalh 


90  HONTGKN   HAV   IN   SPAMSH-AMKUK  AX  WAK. 

the  \iicuiiiii  IxM'diiit's  tui)  liiL;li  liir  tIic  ]iriMliic-tii>ii  ot  the  lu'intiicii  Tins.  In 
this  case  the  vaeuiiiii  caii  lie  lowen-il  li\-  a|iiil\iiiii-  the  tianie  nt'  an  aleohol 
hmip  to  the  siirt'aci-  ut  the  tul)e  so  as  to  wanu  it,  heiiiu'  careful  to  keep  the 
Haine  away  t'roiu  the  wire  terminals  and  in  continual  nuttioii  so  as  to  jtrevent 
lii'eakagc  of  tile  tube  1)\'  overheating;-  in  <ine  place. 

The  tulte  should  always  be  watched  most  carefully  durino-  the  whole 
time  that  it  is  in  operation,  as  the  vacuum  frequently  becomes  lower,  owing 
to  the  iieat  generated  by  the  tiuoresceiue,  and  this  causes  the  platinum 
anode  to  heat  up  very  (pxickly,  which  will  still  further  lower  the  vacuum 
of  the  tulie  and  ultimately  destro^•  ir,  if  ov(-i']ieatinii-  i^  not  checked  bv 
iiio\  ing-  the  rheostat  lever  so  as  to  reiluce  the  current. 

High  vacuum  focus  tubes  retpiire  more  current  to  bring  them  to 
riuorescence  than  do  low  tubes,  and  consecpientlv  the  rheostat  lever  will 
ha\'e  to  be  moved  so  as  to  allow  more  current  than  when  u.sing  a  new  tube. 
P>ut  it  .shoidd  always  be  remembered  that  the  vacuum  decreases,  the  lono-er 
the  tube  is  in  continuous  operation,  and  consequently,  it  should  be  watched 
so  as  not  to  allow  the  platinum  anode  to  get  hotter  than  a  very  dull  red. 
At  this  temperature,  the  ])est  results  are  obtained  with  a  high  vacuum  tul)e 

When  the  vacuum  in  a  focus  tube  rises  very  high,  the  surface  of  the 
tulie  shoulil  be  cleaned  carefirlly  and  frequently,  as  it  has  a  tendei:c\  to 
to  attract  ] (articles  of  dust  from  the  air,  owing  to  the  intense  electrification 
of  the  g'lass. 

Gitod  alcoiiol  should  always  be  used  in  the  lamp  when  warming  focus 
tubes,  as  a  poor  quality  will  deposit  a  thin  coating  of  carbon  on  the  outside 
surface  of  the  glass,  \\liich  will  cause  a  leakage  aronnd  the  tube. 

The  tube  .shoidd  always  be  kept  perfectly  clean.  This  is  best  accom- 
plished by  wi])ing'  it  with  a  piece  of  damp  tissue  paper. 

RADIOGRAPHY. 

Photography  is  an  indispensable  adjunct  to  Kontgen  ray  work,  as  it 
is  necessar}-  to  supplement  nearly  all  fluoroscopic  examinations  by  this 
agent.  This  arises  from  the  fact  that  the  visual  sense  is  not  sufficiently 
acute,  nor  is  the  outline  shown  on  the  fluorescent  screen  sufficiently  distinct, 
to  enable  an  observer  to  determine  the  finer  details  of  most  objects  through 
which  the  Ki'mtgen  rays  will  work.  Frequently,  in  working  through  the 
thicker  parts  of  the  body,  the  fluorescence  is  not  sufficient  to  enable  the  eye 
to  accitrately  determine  the  outlines  of  an  object  or  to  differentiate  it  from 
.surrounding  objects.      In  such  cases,  accurate  images  can  onl\-  lie  obtaine<l 


RADIOGRAPHY.  91 

Ijy  the  prolonged  action  of  the  Rontgen  rays  upon  a  i)hotogniphic  plate.  Kv 
the  prolonged  action  of  the  rays,  the  sensitized  smface  of  the  plate  stores  uj) 
the  impressions  which  are  received  upon  it,  so  allowing  the  photographic 
])i-o(luction  of  images  which  conld  not  be  discerned  visually. 

Also,  hy  means  of  photography,  a  record  of  the  condition  which  exists 
in  the  part  examined  is  made  possiljle,  and  these  maj-  be  nudtii)lie«l  indefi- 
nitely from  a  single  exposure  by  means  of  prints  from  the  negative.  For 
th''se  reasons,  Rontgen  ray  outfits  should  always  be  sui)plemented  by  suth- 
cient  photographic  material  to  enable  the  operator  to  resort  to  pliotography 
whenever  necessary. 

While  the  technic  of  the  production  of  photographs  by  means  of  t\n; 
R<")ntgen  ray  does  not  differ  materially  from  that  used  in  ordinaiy  photo- 
graphic work,  still  there  are  certain  points,  knowledge  of  which  will  further 
the  operator's  endeavor  to  obtain  good  results.  Of  special  importance  are 
the  plates  used,  tlie  length  of  exposure,  and  the  method  of  develo))ment. 


PHOTOGRAPHIC   PLATES. 

All  photographic  plates  are  not  etpially  applicable  to  radiographic  u.se. 
Plates  for  this  work  should  be  thickly  coated  with  an  emulsion  of  the 
highest  degree  of  sensitiveness.  P^xtreme  sensitiveness  is  retpiisite  for  the 
reason,  that,  compared  with  ordinary  light,  the  Rontgen  rays  have  but  feeble 
action  upon  the  silver  compounds  with  which  photographic  plates  are 
coated.  Conse(|uently,  unless  the  plates  are  rapid — i.  e.,  very  sensitive — 
exposure  will  have  to  be  unduly  prolonged  in  order  to  produce  .satisfactory 
results. 

The  necessity  for  a  thick  coating  to  the  plates  arises  from  the  desira- 
bility of  shortening  exposure  to  the  briefest  possible  time.  The  Ri'lntgen 
rays  do  not  work  upon  the  surface  of  the  sensitized  emulsion  alone,  but 
penetrate  it  and  act  ecpially,  or  nearly  so,  throughout  its  entire  thickness. 
This  may  be  proven  by  superimposing  several,  sensitized,  celluloid  or  paper 
films  and  then  taking  a  radiograph  upon  them.  When  develoi^ed,  the 
image  upon  the  lowest  film  will  show  no  appreciable  ditference  from  that 
upon  the  upjjer.  If  now  the  developed  films  are  superimposed  and  viewed 
by  transmitted  light,  the  parts  acted  upon  by  the  light  will  appear  much 
more  opaque  than  when  each  film  is  viewed  separately.  From  this  il 
follows  that  a  plate  coated  with  a  thick  emulsion,  wlien  exposed  and  devel- 
oped, will,   by  reason  of  the  reduction   of  the  silver  salts   throughout   its 


92  KONTUEN  KAY  IN  SrAMSIl-AMEUlCAN   ^\  AK. 

entire  thickness,  give  more  contrnst  ;iiul  priiitiiiii'  density  than  one  with  a 
thin  coating. 

For  these  reasons,  ])hites  specially  made  and  pnt  on  the  market  for 
R(intgeu  ray  work  are  nsnally  thickly  coated,  and  these  plates  shonld 
nsnally  be  used  in  preference  to  j)lates  made  for  ordinary  photographic 
pnrposes.  Some  ordinai-v  ])lates,  however,  give  excellent  resnlts.  Such 
arc  the  "  (h>uble-coated  "  ami  "  nonhalation  "  plates,  all  of  which  are  thickly 
coated.  Some  ra})id  plates  wliich  are  used  for  ordinary  })hot()graphic  pur- 
poses also  give  excellent  results.  Notable  of  tliese  plates  are  those  made 
l)^•  tlie  Cramer  Ihv  Plate  Comjianv  of  St.  Louis,  Mo,,  witli  which  results 
have  lieen  ol)tained  equal  to  the  l)est  obtained  with  special  plates. 

As  ])hotographic  plates  differ  widely  in  their  applicability  to  Kontg'en- 
rav  work,  comparative  tests  should  always  be  made  before  adopting  a  new 
make.  In  testing  plates,  the  following  method  is  useful:  Place  four  plates 
in  light-tight  envelopes,  and  put  them  side  by  side  in  the  form  of  a  square 
under  the  Crookes  tube.  Place  on  each  plate  a  circular  disk  of  tin,  and  in 
the  center  of  the  disk  a  coin.  Fix  the  anode  of  the  Crookes  tube  directly 
above  the  center  of  the  square  formed  by  the  plates,  so  that  all  the  plates 
will  be  equally  illuminated.  Turn  on  the  current  so  that  the  tube  will  be 
illuminated  and  the  plates  exposed.  Expose  for  about  three  minutes,  and 
then  develop  all  the  plates,  together,  in  the  same  tray,  Avith  the  same 
developer.  Comparison  of  the  finished  negatives  will  show  which  plate  is 
the  most  rapid  by  the  greater  density  of  the  shadow  where  the  rays  have 
worked  through  the  tin  disk,  and  the  contrast  can  be  judged  by  the  relative 
density  betw^een  the  shadow  and  the  part  of  the  negative  outside  of  it. 
Clearness  of  the  negative  and  absence  of  chemical  fog  can  be  judged  from 
that  part  of  the  negati^■e  beneath  the  place  where  the  coin  was  placed,  for 
as  no  rays  can  pass  through  the  coin,  this  part  of  the  negative  should 
appear  perfectly  clear.  By  testing  i)lates  in  this  manner,  an  operator  is 
able  to  judge  the  qualit}'  and  kind  of  plates  w'ith  which  he  is  working. 

The  keeping  quality  of  plates  is  a  matter  of  considerable  importance 
in  radiography  for  military  surgical  purposes.  Plates  frequently  have  to 
lie  bought  in  large  quantities  and  shipped  to  distant  points,  often  to  tropical 
climates,  where,  unless  the  plates  have  exceptionally  good  keeping  quali- 
ties, they  are  liable  to  spoil.  Under  such  circumstances,  if  plates  deteriorate, 
it  is  difficult  to  replace  them  without  consideral)le  delay.  Some  kinds  of 
Rontgen-ray  plates  are  put  up  separately  in  light-tight  envelopes.  These 
jdates  do  not  keep  well,  as  the  heat  and  moisture  acts  in  some  way  upon 
the  paper  and  cause  deterioration  in  the  sensitized  stn-faces  of  the  plate  with 


RONTGEN  RAY  BURNS.  93 

which  the  paper  conies  in  contact.  Plates  keep  better  wlien  i)acke(l  toj^ether 
in  Hglit-tight  pasteboard  boxes,  as  they  are  ordinaril\-  packed  foi-  cimnuer- 
cial  use.  For  these  reasons,  plates  packed  in  snch  boxes,  with  en\elopes 
separate,  should  be  chosen.  Radiographs  can  be  taken  ujjon  certain  kinds 
of  sensitized  paper;  such  as  the  P^astman  permanent  bromide.  Tliese  papers 
are,  however,  much  slower  than  plates,  and  do  not  give  as  clear  and  well- 
detined  pictures. 


EXPOSURE. 

The  leng-th  of  exposiire  depends  upon  the  amount  of  radiation  from 
the  tul)e,  the  distance  of  the  tube  from  tlie  plate,  tlu-  rapiditv  of  tlic  plate, 
and  the  density  of  the  part  through  which  the  rays  have  to  work.  Some 
ex])erience  is  required  on  the  part  of  an  operator,  in  order  to  estimate  the 
length  of  time  it  is  necessary  to  subject  the  plate  to  the  action  of  the  rays, 
to  obtain  a  satisfactory  image.  Relative  to  this,  it  may  be  said;  that,  in 
order  to  take  a  satisfactorj'  radiograph  through  anv  of  the  thicker  parts  of 
the  body,  such  as  the  knee,  thigh,  or  head,  it  is  essential  that  the  tube 
should  show  the  shadow  of  an  object  on  the  fluoroscope  through  the  skull 
of  an  adult.  With  a  tube  having  this  radiation,  placed  at  10  inches  ti'om 
the  bod)',  and  using  a  rapid  plate,  tlie  following  lengths  of  exposure  may 
be  considered  as  the  maximum  necessary: 

Forearm  ami  hand One  to  two  minute.s. 

Shoulder  and  i-heft Ten  minutes. 

Knee Nine  minutes. 

Hip  joint,  head,  and  pelvis Twenty  minutes. 

Unless  radiographs  can  be  taken  of  the  different  parts  named,  in  the 
time  given,  the  tube  is  not  working  properly,  either  from  some  defei't  in 
the  tube  or  the  current  by  which  it  is  excited,  and  the  attention  of  the 
operator  should  be  directed  to  these  defects,  and  he  shonld  cori-ect  them 
rather  than  attempt  to  obtain  a  result  by  prolonging  the  exposure. 

RONTGEN-RAY    BURNS. 

Rontgen-ray  burns  are  usually  produced  by  prolonged  exposm-e  with 
tubes  which  are  not  working  properly.  There  is  very  little  danger  if  the 
apparatus  is  working  well;  for,  with  a  properly  working  apparatus,  prolonged 
exjiosures  or  close  approximation  of  the  tube  to  the  body  is  not  necessar}'. 
But  two  Rontgen-ray  burns  have  been  reported  as  a  result  of  the  use  of 
the  Rontgen-ray  apparatns  during  the  Spanish-American  war.  One  burn 
was  produced  by  a  coil   and  one  by  a  static  machine.     In  each  case,  the 


i>4 


K(')NT(ii:n  kav  in  si'anisii-amkricax  war. 


exposuiv    was    ]in>lunL;c<l    aii<l   tVciniciitly   n'|)(-ate(l,  and  tlic  ajipanitiis  was 
imt  \V(H-kiiii:-  at  its  iiiaxiuiimi.      Tlic  cases  are  as  follows: 

Oa«e  1. — Sifii-i.  Rdiiliii  ii-fitij  liiirii  III/  (■nil  iiiiicli'i  III . 

Thomas  McKciiiui.  (liscliar<i('(l  soldier,  fornu'ily  private.  Coiiipanv  C.  Sixth 
riiited  States  Infaiitrv.  had  reeeived  a  uiinsliot  fracture  of  the  iijjper  third  of  tlie 
ii<;iit  liuiiienis  durin<>-  the  Santiatfo  caiiiiiaion.  tor  which  an  (<xcisioii  of  the  iqjper 
part  of  the  huinenis  was  made. 

Decenilier  5.  ISiiS.  an  attempt  was  made  to  radioyrapii  the  shoulder  in  order 
to  ascertain  the  condition  of  tiie  hone.     An  exposure  of  twenty  minutes  was  made, 


Fi(..  2.5. — Rr>nt«rt>n-i;iy  Imni  "t  rifriit  lucast  dl  Tliomas  .MiKi-iiiiii,  t'onnerly  jirivatc  Company  (',  Sixtli 
riiited  States  Inlaiitry.     The  iili(it(>,sri'a|ili  was  taken  when  tlie  ('(nulitioii  was  at  its  wni-st  sta^re. 

usinj)'  a  Fessendeii  coil  machine  actuated  by  a  dynamo  current,  with  the  tube  (si  low 
one)  1(»  inches  from  the  shoulder.  The  result  was  so  unsucce.ssful  that  a  second  tind 
tiiird  trial  on  successive  days  were  made,  ))ut  the  tube  was  working-  so  poorly  that  no 
satisfactory  radiooraph  wtis  obtained.  Six  days  after  the  la.st  exposure,  slight 
redness  of  the  skin  iippeared  on  the  front  of  the  chest  and  shoulder.  This  erythe- 
matous condition  increased  and,  two  days  later,  small  l)lel)s  iippetired.  These  broke 
and  sniidl  idcers  formed,  whicii  yradually  spread  and  cotilesced.  The  tissue  necrosis 
deepeneil  and  extended  and  was  ;iccompaiiii'<l    by  marked  piiin   and  hypera'stiiesia. 


R()i\T(iE\  UAY  BrK.NS. 


i)') 


Tile    illllillimiatorv  actinii    (•(mtiliuril    until    llic    lini-ii    covi'I-imI    iii';U-|\-    tlir    wliulc    i-'hjlil 

hreast  (liu-.  ■2:>). 

Treatineiit  of  \:iriou.skiiid.s  wa.s  irictl,  l)ut  tlic  greatest  hcm'tit  \\a>  (In-hcd  fiinii 
continuous  application  of  lead  and  opium  lotion.  Tlic  Imiii  showed  no  sion  of  heal- 
iny  fof  four  months.  After  that  time  it  <iraduai]\  jirew  better,  hut  thi'  healin<r 
process  wa.s  very  slow  and  the  ))urn  was  not  entirely  heale(l  until  elexcn  months  after 
its  first  appearance. 

('(lxr'2.  —  SIkjI)!.   liiiiit(l<ii   rilijliitrii  In/  stutir  nxir/iin, . 

Walter  C.  Hooth.  private.  Hospital  Corps.  Admitted  to  the  Army  (ieni'ral 
Hospital  at  ^\'ashine■ton   Haii-acks.  I).  C.  ^larcli    14.  isKii.   foi-  pyelitis  and  Indro- 


\-u,.  2li. — RJmtsen-ray  Imrn  on  the  abili)iiicii  el'  Walter  (.'.  ISeetli,  |iiivale.  Ilcis|iilal  ('iir]is.     The  jilio- 
tDfirajih  was  taken  when  the  I'rytlu'niatons  conilitieii  was  at  its  hei^'ht. 

nephrosis  of  the  left  kidney,  supposed  to  he  due  to  the  presence  of  etdcidus  in 
the  pelvis  of  that  kidney.  An  attempt  was  made  to  determine  hy  liulioe-raphy 
whether  or  not  a  calculus  was  present.  Exposures  of  twenty-ti\e  miiuites  eiuh  were 
made  every  other  day  for  three  days  with  a  static  niiU'hine,  Init  no  calculus  was  found. 
Five  days  after  the  la.st  exposure,  an  erythematous  spot  appeared  on  the  left  side 
of  the  abdomen.  This  yraclually  became  (iiute  pronounced  in  color  and  spretid  until 
it  reached  the  size  shown  in  liy.  '>i\.     There  was  hyperesthesia  of  the  part,  but   no 


96  KONTGEN  ray  in  SPANISH- A.MERICAN  WAR. 

ulfenition  occuircd.  and  llic  irTitiition  disapppiirt'd  in  uhmit  tt'ii  days.  IcaviiiL;'  no  after 
etferts. 

It  appears  that  tlu*  factors  which  influence  the  production  of  Rontgen 
ray  burns  are :  («)  the  length  of  the  exposure ;  (h)  the  nearness  of  the  tube  to 
the  surface  of  the  1  kxIv  ;  (c)  the  physical  condition  of  the  patient,  and  (f/)  indi- 
vidual idiosyncras\'.  Relative  to  the  length  of  ex])osure ;  it  should  not  exceed 
thirty  minutes,  for  with  this  length  of  exposure  any  part  of  the  body  may 
be  radiographed,  2>i'ovided  the  apparatus  is  working  properly  and  good 
technic  is  ust'd.  If  photographic  results  are  not  obtained  with  a  thirty- 
minute  exposure,  the  ojierator  should  look  to  improving  his  apparatus  or 
technic  rather  than  to  lengthening  the  time  which  he  exj)oses  the  patient  to 
the  action  of  the  rays. 

In  regard  to  the  distance  of  the  tube  from  the  bod)' ;  ten  inches  should 
be  taken  as  the  minimum  distance.  There  is  no  doubt  that  the  nearer  the 
tube  is  to  the  surface  of  the  body,  the  more  likelihood  there  is  of  producing 
a  burn.  A  good  apparatus,  ])roperly  adjusted,  will  work  readily  through 
the  head,  chest,  or  pelvis  with  the  tube  at  ten  inches;  and,  in  tlie  absence 
of  individual  idiosyncrasy,  witli  the  tube  at  that  distance,  and  an  exposure 
not  exceeding  thirty  minutes,  there  is  no  danger  of  a  burn. 

Personal  idiosvncras^■  and  low  \'itality  have  always  to  be  taken  into 
account.  The  first,  fortunately,  is  very  rare,  as  it  can  not  be  determined 
beforehand;  tlie  latter  should  always  be  considered.  A  person  in  ill  health 
or  debilitated  in  any  way  is  undoubtedly  more  likely  to  be  burned  by  the 
Rontgen  rays  than  one  who  is  strong  and  vigoroi;s.  The  well-known  fact 
that  weakened  tissues  easily  yield  to  disturbing  forces,  holds  with  the  action 
of  the  Rontgen  rays  as  with  other  factors,  the  action  of  which,  if  too  long 
continued,  devitalizes  the  cells.  Exposures  frequently  repeated,  with  too  little 
interval  of  time  between  them,  will  act  in  the  same  way  as  a  single  long 
ex})osure;  the  tissues  disturbed  by  one  exposure  not  being  able  to  regain  their 
equilibrium  before  the  second  exposure  is  made.  It  is  to  be  remembered 
that  the  pathological  efl"ect  of  a  destructive  Rontgen  ray  exposure  is  not  at . 
once  apparent,  the  first  appearance  of  ;i  burn  not  showing  itself  for  two  or 
three  days.  It  is  quite  possible,  therefore,  to  seriously  increase  a  trouble 
already  started,  if  a  second  exposure  is  made  within  tJiat  time.  For  this  rea- 
son, it  is  a  good  rule,  wliere  a  thirty-minute  exposure  has  been  made,  not  to 
repeat  the  exposure  within  three  days.  With  exposures  of  shorter  duration, 
the  danger  of  repetition  diimmahea  pari  passu  with  the  length  of  the  exposure. 


DEVELOPMENT  OF  NEGATIVES.  97 

DEVELOPMENT    OF    RONTGEN-RAY    NEGATIVES. 

The  development  of  Rontg:en-ray  uegjitive.s  doe«  not  ditFer  from  tliat  of 
ordmaiy  nefj^atives,  except  that  more  time  i.s  usually  required  to  1)rin<i-  out 
the  details  and  obtain  sufficient  contrast.  Any  developer  which  will  produce 
good  results  in  ordinary  photography,  will  produce  good  results  in  Rnntgen- 
ray  work.  Of  the  ditferent  developing  agents,  pyrogallic  acid,  metol,  ludio- 
chinone,  and  ortol  are  the  best.  Pyi-o  is  probably  the  best  when  pi-opcrK- 
used,  Ijut  it  has  the  disadvantage  of  staining  the  hands  of  the  operator. 
This  may  be  overcome  by  the  use  of  rubber  gloves,  and  where  iiiucli 
Rontgen  work  is  to  be  done,  pyrogallic  acid  is  probably  the  l)est  i-cducing 
agent  that  can  be  employed.  The  following  fornnda  foi-  its  u.se  will  be 
f6und  a  good  one: 

A. 

fJrams. 

Boiled  water .500 

Potassium  bromide 1 

Suljihite  of  .soda \-Jr> 

B. 

Boiled  water .500 

Sodium  carbonate 12.5 

To  develop,  take  of  A,  30  grams;  B,  30  grams;  water,  200  grams:  ])\ro- 
gallic  acid,  one-third  teaspoonful  of  dry  crystals.  By  making  the  developer 
up  as  given,  and  using  dry  pyrogallic  acid,  uniform  action  of  the  developer 
is  insured,  as  develo])ers  made  up  with  pyrogallic  acid  in  solution  are  very 
apt  to  deteriorate.  Metol  and  hydrochinone,  while  not  having  the  staining 
qualities  of  pyro,  do  not  give  negatives  with  quite  as  good  printing  quali- 
ties. Developers  in  which  they  are  used  are  also  somewhat  more  difficidt 
to  make  up.  But,  where  thei'e  is  objection  to  the  use  of  pyro,  the  following 
formula  will  be  found  an  excellent  one: 

(irams. 

Boiled  water 500 

Sodium  sulphite 50 

Potassium  liroraide 1 

Metol 2 

Hydrochinone 6 

Sodium  carbonate,  crystallized 50 

When  great  contrast  is  desii-ed,  hydrochinone  alone,  with  a  caustic 
alkali  as  an  accelerator,  and  some  potassium  bromide  as  a  restrainer,  will 
give  best  results.  Ortol  gives  good  negatives  and  has  the  advantage  of 
being  ready  mixed,  only  requiring  to  be  dissolved  in  water. 


OS  RANTGEN  ray  IX  SIWMSII-AMERICAN  AVAR. 

For  iixiug   tliu   neii'ativc,    an   aciil-iixiiiy   bath,  with   i-liroiiio   ahiiii,  is 
better  than  a  plain  solution  of  sodium  hyposulphite  in  water.      The  acid 
bath  removes  stains  from  the  negative  and  hardens  the  gelatin ;  an  important 
detail  in  hot  weather  or  warm  climates. 
The  following-  formula  is  a  good  one: 

Water lul <u-  (■ctUiiiu'tei's. .  2, 000 

Hyposul]iliiti'  (if  suila itrams. .      7.50 

Sulphite  (if  s(i(Ui - do 60 

Chrome  ahuu do SO 

Suliihnrie  acid (.■uhic  tviitimetere. .  4 

This  solution  shoidd  be  hltered  before  using.  Where  chrome  alum 
can  not  be  olitained,  ordinary  alum  may  be  used,  but  the  solution  Avill 
require  more  frequent  filtering. 

PRINTING. 

When  prints  are  to  be  made  from  Huntgen-ray  negatives,  any  good 
printing-out  paper  may  be  used.  Where  it  is  necessary  to  retain  all  the 
iiner  details  of  the  negative,  Solio,  Aristo,  or  any  one  of  the  modern  gelatin 
or  collodion  papers,  will  give  very  good  results.  For  the  very  best  results, 
however,  albumen  paper  is  unequaled.  It  has  the  disadvantage  of  requiring 
more  experience  on  the  part  of  the  photographer  ;i,nd  of  being  more 
difHcult  to  manipulate  than  the  printing-out  papers  which  have  been 
recenth^  put  on  the  market. 

For  })rints  wdiich  are  to  be  quickly  ])roduced,  one  of  the  Ijromide 
pa|)ers  can  be  used,  but  these  papers  do  not  give  as  fine  detail  as  do  the 
gellatiu,  collodion,  or  allnimen  printing-out  papers. 

All  the  manii)ulations  of  Rontgen-ray  photography  are  similar  to  those 
of  ordinarv  jdiotography,  and  anyone  who  has  mastered  the  teclmic  of 
the  latter  will  have  no  difficult v  in  Rontyen-rav  work.  Pliotoa'rai )h v  is, 
however,  alisolutely  essential;  as  the  fluoroscope,  alone,  will  show  onh-  a 
minority  of  the  conditions  which  the  Rontgen  ray  is  capable  of  disclosing. 
Every  Rihitgcn-ray  apparatus  should,  therefore,  be  supplemented  by  a 
conqjlete  outfit  for  photographic  w'ork. 


OXIV 


jsaoM 


